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.

Aggressive vertebral hemangioma

Aggressive vertebral hemangioma

Accurate preoperative diagnosis is essential because they are highly vascular with a high tendency for intraoperative bleeding.

Management of aggressive VHs involves pre-op embolization, spinal surgery, and reconstruction. Pain management, physical rehabilitation, and close neurological follow-up are imperative to near-total recovery 1).

Surgery is required in cases of rapid or progressive neurological symptoms like compressive myelopathy or radiculopathy.

Vertebral hemangioma resection can be a real challenge for spine surgeons, given the high potential of massive intraoperative bleeding. For this reason, preoperative transarterial embolization of this tumor is supported by the available literature 2).


A navigation-guided drill is highly helpful for real-time monitoring of ongoing tumor resection. It enables safely resection of the tumor, especially in the anterior cortical surface of the vertebral body, and easily resections even hard tumors. This method results in reducing residual tumors and maintaining safe resection 3).

Radiotherapy can be used in patients with slowly progressive neurological deficits.

While CT-guided direct alcohol injection is effective in the management of symptomatic and aggressive vertebral hemangiomas, spinal angiography and trans-arterial embolization of the blood supply to the vertebral body hemangioma, prior to the direct transpedicular alcohol embolization of the lesion, improves the safety of the procedure 4).

Other emerging options in cases of aggressive hemangiomas include radiofrequency ablation with a hemostatic agent (e.g. FLOSEAL, Baxter, USA), and bone autograft placement 5).


Minimally invasive procedures may be successful in smaller lesions 6).

The case of a pregnancy who was diagnosed with an aggressive vertebral hemangioma that further led to progressive paraparesis. We had to take the fact that she was pregnant into account in the diagnostic procedure, the choice of examination method, and also the method of therapy. The goal of this case report is threefold: (1) provide an overview of the possible methods of management, specifically imaging, which will aid in diagnosis and based on that, (2) determine the appropriate therapy, and (3) review the risks and benefits of each will be presented when choosing individual approaches 7).


1)

Goraya GS, Singhal S, Paul BS, Paul G. Aggressive Vertebral Hemangioma: The Mystery of Spastic Legs Unveiled by a Purple Shoulder. Cureus. 2022 Jan 24;14(1):e21568. doi: 10.7759/cureus.21568. PMID: 35228927; PMCID: PMC8873442.
2)

Fiore G, Bertani GA, Tariciotti L, Borsa S, Paolucci A, Taramasso L, Locatelli M, Pluderi M. Vertebral Body Infarction after Transarterial Preoperative Embolization of a Vertebral Hemangioma. J Neurol Surg A Cent Eur Neurosurg. 2021 Dec 12. doi: 10.1055/s-0041-1739215. Epub ahead of print. PMID: 34897610.
3)

Nagashima Y, Nishimura Y, Haimoto S, Eguchi K, Awaya T, Ando R, Akahori S, Hara M, Natsume A. Piecemeal resection of aggressive vertebral hemangioma using real-time navigation-guided drilling technique. Nagoya J Med Sci. 2021 Nov;83(4):861-868. doi: 10.18999/nagjms.83.4.861. PMID: 34916728; PMCID: PMC8648519.
4)

Srinivasan G, Moses V, Padmanabhan A, Ahmed M, Keshava SN, Krishnan V, Joseph BV, Raju KP, Rajshekhar V. Utility of spinal angiography and arterial embolization in patients undergoing CT guided alcohol injection of aggressive vertebral hemangiomas. Neuroradiology. 2021 Nov;63(11):1935-1945. doi: 10.1007/s00234-021-02788-7. Epub 2021 Aug 24. PMID: 34427707.
5)

Canbay S, Kayalar AE, Gel G, Sabuncuoğlu H. A novel surgical technique for aggressive vertebral hemangiomas. (2019) Neurocirugia (Asturias, Spain). 30 (5): 233-237. doi:10.1016/j.neucir.2018.08.003
6)

Vasudeva VS, Chi JH, Groff MW. Surgical treatment of aggressive vertebral hemangiomas. Neurosurg Focus. 2016 Aug;41(2):E7. doi: 10.3171/2016.5.FOCUS16169. PMID: 27476849.
7)

Ridzoňová L, Fedičová M, Andráš T, Urdzík P, Gdovinová Z. Lower-limb progressive paraparesis management and diagnosis overview in a pregnant woman with vertebral haemangioma. Womens Health (Lond). 2022 Jan-Dec;18:17455057221099018. doi: 10.1177/17455057221099018. PMID: 35574823.

Microvascular decompression for trigeminal neuralgia outcome

Microvascular decompression for trigeminal neuralgia outcome

Microvascular decompression (MVD) is the most effective long-term surgical treatment for trigeminal neuralgia (TN) patients. The risk factors for poor pain control following MVD surgery are not fully understood.


A significant proportion of patients with significant neurovascular compression fail to achieve long-term pain relief after technically successful surgery. Neuroimaging using magnetic resonance imaging (MRI) provides a non-invasive method to generate objective biomarkers of eventual response to TN surgery 1).


Younger patients with TN had worse long-term pain outcomes following MVD. Additional factors associated with postoperative recurrence included poor preoperative pain control (BNI score > IV) and multivessel compression. Furthermore, SCA combined with PV was confirmed to be associated with a worse outcome 2).


Not all patients with TN manifest unequivocal neurovascular compression (NVC). Furthermore, over time patients with an initially successful MVD manifest a relentless rate of TN recurrence.

It does not achieve 100 % cure rate. Re-exploration of the posterior fossa may carry increased risk over first-time MVD and is not always successful, so other treatments are needed.


Age itself does not seem to represent a major contraindication of microvascular decompression for typical trigeminal neuralgia 3).

Patients 60 yr of age and older have significantly better long-term pain outcomes following MVD than younger patients 4).


1)

Wang Z, Zhao Z, Song Z, Wang Y, Zhao Z. The application of magnetic resonance imaging (MRI) for the prediction of surgical outcomes in trigeminal neuralgia. Postgrad Med. 2022 May 3:1-7. doi: 10.1080/00325481.2022.2067612. Epub ahead of print. PMID: 35503235.
2)

Shi J, Qian Y, Han W, Dong B, Mao Y, Cao J, Guan W, Zhou Q. Risk factors for outcomes following microvascular decompression for trigeminal neuralgia. World Neurosurg. 2020 Jan 17. pii: S1878-8750(20)30100-5. doi: 10.1016/j.wneu.2020.01.082. [Epub ahead of print] PubMed PMID: 31958591.
3)

Mastronardi L, Caputi F, Rinaldi A, Cacciotti G, Roperto R, Scavo CG, Stati G, Sufianov A. Typical Trigeminal Neuralgia: Comparison of Results between Patients Older and Younger than 65 Operated on with Microvascular Decompression by Retrosigmoid Approach. J Neurol Surg A Cent Eur Neurosurg. 2019 Aug 29. doi: 10.1055/s-0039-1693126. [Epub ahead of print] PubMed PMID: 31466107.
4)

Bick SK, Huie D, Sneh G, Eskandar EN. Older Patients Have Better Pain Outcomes Following Microvascular Decompression for Trigeminal Neuralgia. Neurosurgery. 2019 Jan 1;84(1):116-122. doi: 10.1093/neuros/nyy011. PubMed PMID: 29562363.
WhatsApp WhatsApp us
%d bloggers like this: