Pneumocephalus clinical features

Pneumocephalus clinical features

Pneumocephalus may be a causative factor for post-craniotomy pain and headache with surgical injuries 1).


Clinical presentation includes headaches in 38 %, nausea and vomitingseizures, hemiparesisdizzinessobtundation and depressed neurological status 2).


An intracranial succussion splash is a rare (occurring in ≈ 7%) but pathognomonic finding. Tension pneumocephalus may additionally cause signs and symptoms just as any mass (may cause focal deficit or increased ICP).

A minority of patients describe ‘bruit hydro-aerique’ (a splashing noise on head movement, equivalent to the succussion splash of pyloric stenosis) 3).

This noise may also be audible to the examiner with the aid of a stethoscope.


Patients often report sounds in the head after craniotomy.

In a prospective observational study of patients undergoing craniotomy with dural opening. Eligible patients completed a questionnaire preoperatively and daily after surgery until discharge. Subjects were followed up at 14 days with a telephone consultation.

One hundred fifty-one patients with various pathologies were included. Of these, 47 (31 %) reported hearing sounds in their head, lasting an average 4-6 days (median, 4 days, mean, 6 days, range, 1-14 days). The peak onset was the first postoperative day and the most commonly used descriptors were ‘clicking’ [20/47 (43 %)] and ‘fluid moving’ in the head [9/47 (19 %)]. A significant proportion (42 %, 32/77) without a wound drainage experienced intracranial sounds compared to those with a drain (20 %, 15/74, p < 0.01); there was no difference between suction and gravity drains. Approximately a third of the patients in both groups (post-craniotomy sounds group: 36 %, 17/47; group not reporting sounds: 31 %, 32/104), had postoperative CT scans for unrelated reasons: 73 % (8/11) of those with pneumocephalus experienced intracranial sounds, compared to 24 % (9/38) of those without pneumocephalus (p < 0.01). There was no significant association with craniotomy site or size, temporal bone drilling, bone flap replacement, or filling of the surgical cavity with fluid.

Sounds in the head after cranial surgery are common, affecting 31 % of patients. This is the first study into this subject, and provides valuable information useful for consenting patients. The data suggest pneumocephalus as a plausible explanation with which to reassure patients, rather than relying on anecdotal evidence, as has been the case to date 4).


Rapid neurologic deterioration following craniofacial resection may be caused by the development of tension pneumocephalus 5).


1)

Kim TK, Yoon JR, Kim YS, Choi Y, Han S, Jung J, Park IS. Pneumocephalus and headache following craniotomy during the immediate postoperative period. BMC Surg. 2022 Jun 29;22(1):252. doi: 10.1186/s12893-022-01701-0. PMID: 35768812.
2)

Markham JW. The clinical features of pneumocephalus based upon a survey of 284 cases with report of 11 additional cases. Acta Neurochir (Wien). 1967;16(1):1-78. PubMed PMID: 6032371.
3)

Zasler ND, Katz DI, Zafonte RD. Brain Injury Medicine, Principles And Practice. Demos Medical Publishing. (2007) ISBN:1888799935.
4)

Sivasubramaniam V, Alg VS, Frantzias J, Acharya SY, Papadopoulos MC, Martin AJ. ‘Noises in the head’: a prospective study to characterize intracranial sounds after cranial surgery. Acta Neurochir (Wien). 2016 Aug;158(8):1429-35. doi: 10.1007/s00701-016-2872-7. Epub 2016 Jun 21. PubMed PMID: 27328839.
5)

Yates H, Hamill M, Borel CO, Toung TJ. Incidence and perioperative management of tension pneumocephalus following craniofacial resection. J Neurosurg Anesthesiol. 1994 Jan;6(1):15-20. PubMed PMID: 8298259.

Hemispherectomy for Rasmussen’s encephalitis

Hemispherectomy for Rasmussen’s encephalitis

Compared with functional hemispherectomy and hemisphere disconnection, anatomical hemispherectomy elicited better seizure outcomes with an acceptable level of complications. Early-stage operations might lead to better cognitive status, but they are associated with a high risk of IQ decline 1).


Obtaining complete disconnection is critical for favorable seizure outcomes from hemispherectomy, and neurosurgeons should have a low threshold to reoperate in patients with Rasmussen’s encephalitis with recurrent seizures. Rapid progression of motor deficits and bilateral MRI abnormalities may indicate a subpopulation of patients with RE with an increased risk of needing reoperation. Overall, they believe that hemispherectomy is a curative surgery for the majority of patients with RE, with excellent long-term seizure outcome2).


The majority of pediatric patients undergoing resection or hemispherectomy for RE achieve good seizure outcome. Although small retrospective cohort studies are inherently prone to bias, the best available evidence utilizing individual participant data suggests hemispheric surgery and younger age at the surgery are associated with good seizure outcomes following epilepsy surgery. Large, multicenter observational studies with long-term follow-up are required to evaluate the risk factors identified in a review 3).


Hemispherotomy remains the gold standard treatment but causes permanent functional impairment. No standardized medical treatment protocol currently exists for patients prior to indication of hemispherotomy, although some immunotherapies have shown partial efficacy with functional preservation but poor antiseizure effect. Some studies suggest a role for tumor necrosis factor alpha (TNF-α) in RE pathophysiology.


1)

Guan Y, Chen S, Liu C, Du X, Zhang Y, Chen S, Wang J, Li T, Luan G. Timing and type of hemispherectomy for Rasmussen’s encephalitis: Analysis of 45 patients. Epilepsy Res. 2017 May;132:109-115. doi: 10.1016/j.eplepsyres.2017.03.003. Epub 2017 Mar 22. PMID: 28399506.
2)

Sundar SJ, Lu E, Schmidt ES, Kondylis ED, Vegh D, Poturalski MJ, Bulacio JC, Jehi L, Gupta A, Wyllie E, Bingaman WE. Seizure Outcomes and Reoperation in Surgical Rasmussen Encephalitis Patients. Neurosurgery. 2022 May 13. doi: 10.1227/neu.0000000000001958. Epub ahead of print. PMID: 35544031.
3)

Harris WB, Phillips HW, Chen JS, Weil AG, Ibrahim GM, Fallah A. Seizure outcomes in children with Rasmussen’s encephalitis undergoing resective or hemispheric epilepsy surgery: an individual participant data meta-analysis. J Neurosurg Pediatr. 2019 Dec 6:1-10. doi: 10.3171/2019.9.PEDS19380. [Epub ahead of print] Review. PubMed PMID: 31812145.

Shunt for Idiopathic normal pressure hydrocephalus treatment

Shunt for Idiopathic normal pressure hydrocephalus treatment

• Early shunt surgery can significantly improve the clinical symptoms and prognosis of patients with idiopathic normal pressure hydrocephalus (iNPH). • Structural imaging findings have limited predictiveness for the prognosis of patients with iNPH after shunt surgery. • Patients should not be selected for shunt surgery based on only structural imaging findings 1).


Clinical decisions regarding Shunt for Idiopathic normal pressure hydrocephalus treatment should be individualized to each patient, with adequate consideration of the relative risks and benefits, including maximizing a healthy life expectancy 2).

see Ventriculoperitoneal shunt for idiopathic normal pressure hydrocephalus.

see Lumboperitoneal shunt for idiopathic normal pressure hydrocephalus.


1)

Chen J, He W, Zhang X, Lv M, Zhou X, Yang X, Wei H, Ma H, Li H, Xia J. Value of MRI-based semi-quantitative structural neuroimaging in predicting the prognosis of patients with idiopathic normal pressure hydrocephalus after shunt surgery. Eur Radiol. 2022 Apr 30. doi: 10.1007/s00330-022-08733-3. Epub ahead of print. PMID: 35501572.
2)

Nakajima M, Kuriyama N, Miyajima M, Ogino I, Akiba C, Kawamura K, Kurosawa M, Watanabe Y, Fukushima W, Mori E, Kato T, Sugano H, Tange Y, Karagiozov K, Arai H. Background Risk Factors Associated with Shunt Intervention for Possible Idiopathic Normal Pressure Hydrocephalus: A Nationwide Hospital-Based Survey in Japan. J Alzheimers Dis. 2019 Mar 11. doi: 10.3233/JAD-180955. [Epub ahead of print] PubMed PMID: 30883349.
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