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NEURORADIOLOGY Table of Contents   
Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 735-738
Post traumatic intracerebral pneumatocele presenting as CSF rhinorrhoea - A case report


Department of Radiodiagnosis, Bhopal Memorial Hospital and Research Centre, Bhopal-462038, India

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Date of Submission14-Mar-2006
Date of Acceptance10-Aug-2006
 

Keywords: Intracerebralpneumatocele, CSF rhinorrhoea

How to cite this article:
Gupta S, Venkatesh S K, Gupta N, Patel K. Post traumatic intracerebral pneumatocele presenting as CSF rhinorrhoea - A case report. Indian J Radiol Imaging 2006;16:735-8

How to cite this URL:
Gupta S, Venkatesh S K, Gupta N, Patel K. Post traumatic intracerebral pneumatocele presenting as CSF rhinorrhoea - A case report. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Aug 24];16:735-8. Available from: http://www.ijri.org/text.asp?2006/16/4/735/32335

   Introduction Top


Pneumatocele is a rare complication following head trauma. Pneumocephalus occurs in 0.5 to 1% of head trauma cases. The pathophysiology is access of air into the cranium through a fracture involving air sinuses or middle ear roof or depressed fracture of skull resulting in a craniodural fistula. To the best of our knowledge, posttraumatic intracerebral pneumatocele in communication with ventricular system has not been reported earlier in English literature. We report a case of a posttraumatic pneumatocele presenting as cerebrospinal fluid (CSF) rhinorrhoea and having communication with the ventricular system.


   Case report Top


A 30-year-old man presented with headache, fever and vomiting of 7 days duration. He also complained of persistent nasal discharge of clear fluid since 7 days. He gave history of fall from bicycle 8 weeks back, following which he was unconscious and was admitted at another hospital. He had a bout of epistaxis 4 days after the trauma and recovered within a week and was discharged. No other investigations were done at that time.

On examination he had spasticity of left upper limb and was febrile with signs of meningeal irritation. The clear fluid from the nose was subjected to biochemical analysis and was consistent with CSF. CT scan of head revealed depressed fractures of both tables of right frontal sinus and fracture of ethmoid air cells [Figure - 1]. There were subarachnoid and cisternal hypodensities suggestive of air. A large cavity with air-fluid level was seen in the right frontal lobe. There was communication between this cavity and frontal horn of right lateral ventricle, which appeared compressed in comparison to the left lateral ventricle along with some midline shift towards left side. No evidence of any rim enhancement was seen on post contrast CT scan. Subsequently MRI of brain was performed. On T2- weighted axial images, there was evidence of an air fluid level in the right frontal region and also evidence of air in the ventricles [Figure - 2]a and no abnormal enhancement was noted in the post contrast T1- weighted images around the pneumatocele. However, evidence of meningeal enhancement was seen suggesting changes of early meningitis. CSF was seen in the ethmoid air cells and frontal sinus. Sagittal image [Figure - 2]b and coronal images in prone position with extended neck [Figure - 3],[Figure - 4] demonstrated the two-way communication of the pneumatocele to ethmoid air cells and to the frontal horn of right lateral ventricle.

Patient was treated for meningitis with broad-spectrum antibiotics. After three weeks of treatment for meningitis and after improvement of CSF composition, the patient was operated by bifrontal craniotomy. Intraoperatively, there were infected depressed fractures of anterior and posterior wall of right frontal sinus and fracture of roof of ethmoid air cells. There were gliotic changes in brain substance over the right orbital surface and was seen to herniate into the cribriform plate. The fractured fragments of air sinuses were removed along with the sinus mucosa. The sinuses were packed with antibiotic soaked gelfoam and wax. Superior sagittal sinus at crista was ligated and intradural seperation of inferiorly herniated brain substance in cribriform plate was done Pericranial flap was raised, covering the midline anterior cranial fossa well beyond the basal defect and stitched almost watertight over the basal dura. The cavity (pneumatocele) was not explored, as there was no suggestion of infection or raised pressure in preoperative CT and MRI. Postoperative period was uneventful, patient showed clinical improvement and there was no CSF rhinorrhoea. Follow up MRI done two weeks after surgery showed decrease in the amount of air in the pneumatocele, which was replaced by CSF with reduction in the mass effect [Figure - 5]. There was no CSF in the repaired frontal sinus and ethmoidal air cells. AT 6 weeks post-op, patient is asymptomatic and on follow-up.


   Discussion Top


Presence of intracranial gas or air in an unintervened patient (non-iatrogenic) is abnormal. Non iatrogenic intracranial air entry is possible only when a craniodural fistula develops [1]. A ball valve mechanism may allow air to enter but not exit the cranium or a CSF leak permits air entrance as fluid leaves the intracranial space [1],[2]. Air in the subarachnoid or subdural space is diagnostic for a dural tear and for a potential CSF fistula somewhere in the intracranial cavity. Pneumocephalus following surgery or as a result of eroding infection or neoplasm is common [2]. Other reported causes of pneumocephalus include gunshot injury [3],[4], frontal sinus osteoma [5],[6], intraventricular drainage [7], spontaneous cure of intracerebral haematoma by drainage into middle ear and replacement of the haematoma by air [8] and following manually operated ventilation with a mask [9]. Air in brain parenchyma following head injury involving the fracture of air sinuses could also be due to cortical laceration following impingement of fractured fragments of air sinuses into the brain parenchyma and air dissecting into the parenchyma and collecting into a cavity.

Clinically, patients present with nonspecific symptoms like headache, nausea and vomiting [1],[10]. A "succession splash" is considered diagnostic of pneumocephalus [1]. Rarely patient can present with frontal syndrome [11]. Presentation with CSF rhinorrhoea is late after head injury because immediately after trauma the site of CSF fistula is blocked due to oedema in the acute stage. As the inflammation subsides the oedema resolves and patient presents with CSF rhinorrhoea days to weeks after the trauma [10]. This was also observed in our case. Cases of pneumatocele communicating with sinuses and presenting with CSF rhinorrhoea, 7-12 weeks following trauma have been reported earlier [10],[11], however no communication of the pneumatocele with ventricle were observed in any of these patients.

Pneumocephalus can be easily diagnosed on plain x-ray which may demonstrate an air fluid cavity or a collection of air inside the skull along with evidence of skull base fractures in post-traumatic cases. CT demonstrates the location of pneumatocele and may show associated air fluid level, mass effect, surrounding edema and there may be rim enhancement of the cavity following contrast administration [12]. Imaging is required in these cases to rule out possibility of a gas forming cerebral abscesses. Pneumatocele appears as an hypodense area on CT scan (-900 to -1000 HU) and hypointense in MRI in all sequences. MRI is helpful in demonstrating the communication with the ventricles and subarachnoid space as was in our case. MRI being more sensitive than CT can also demonstrate meningitis which is one of the common complications of pneumocephalus. The multiplanar imaging capability of MRI helps in localization and demonstration of the defect, which is helpful for planning of surgery and further management.

A pneumatocele if not treated promptly after diagnosis of cause can lead to abscess formation acquiring infection from the sinudural fistula [1].Ventriculitis and meningitis are other complications. Therapy is often noninvasive allowing the craniodural defect to heal spontaneously [2], however surgical repair by duraplasty is required to prevent both CSF fistula and infection in selected cases [1]. The present case was successfully operated and treated with base of skull repair and no intervention into the cavity.

In conclusion, a rare case of posttraumatic pneumatocele with two-way communication with the ventricle and air sinus and presenting as CSF rhinorrhoea has been described. The utility of MRI in demonstration of the communication has been highlighted.

 
   References Top

1.Erahn Y, Karabiyikolu M, Mutluer S. Air in intracerebral haematoma. Online Journal of Neurosciences (Turkish) 1999; 16: 1-3  Back to cited text no. 1    
2.Orebaugh SL, Margolis JH. Post traumatic intracerebral pneumatocele: case report. J Trauma 1990; 30:1577-1580   Back to cited text no. 2  [PUBMED]  
3.Shoung HM, Sichez JP, Pertuiset B: The early prognosis of craniocerebral gunshot wounds in civilian practise as an aid to the choice of treatment. Acta Neurochir(Wien)1998;74 : 27-30.  Back to cited text no. 3    
4.Portmann D, Herman D , Got M : Pneumatocele caused by ballistic injury of the anterior stage of the skull base , a case report. Rev Laryngol Otol Rhinol ( Bord) 1990; 111 : 239-43.  Back to cited text no. 4    
5.Rappaport JM, Attia EL: Pneumocephalus in frontal sinus osteoma : a case report. J Otolaryngol 1994; 23: 430-36.  Back to cited text no. 5    
6.Mandelson DB , Hertzmanu Y , Friedman R. Frontal osteoma with spontaneous subdural and intracerebral pneumatocele . J Laryngol Otol 1984; 98: 543-45.  Back to cited text no. 6    
7.Witcombe JB, Torreus MJ, Gye.RS. Intracerebral pneumatocele: an unusual complication following intraventricular drainage in case of benign intracranial hypertension. Neuroradiology 1976: 12: 161-63.  Back to cited text no. 7    
8.Bose B, Kraut W, Osterholm JL. Intracerebral haematoma: spontaneous cure by drainage into the middle ear. A case report. Neurosurgery 1982; 10: 103-104   Back to cited text no. 8    
9.Dacosta A, Billard JL, Grey P, Vermesch R, Bertand M, Bertand JC. Post traumatic intracerebral pneumatocele after ventilation with a mask: case report. J Trauma 1994; 36: 255-257.  Back to cited text no. 9    
10.Huang CF, Chou TY,Chang CK. Traumatic tension pneumocephalus/intracerebral pneumatocele : a case report.Gaox Xue Za Zhi 1992 ;8 :113-16.  Back to cited text no. 10    
11.(Bayassi S: Delayed posttraumatic intracerebral pneumatocele: a case report and literature. Neurol Neurochir Pol 1997; 31: 1047-51.  Back to cited text no. 11    
12.Mandelson DB, Hertzanu Y. Intracerebral pneumatoceles following facial trauma: CT findings. Radiology 1985: 54:115-18.  Back to cited text no. 12    

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Correspondence Address:
S Gupta
17- MIG, Nillo Villa, Housing Board Colony, Sector A, Kohe-Fiza, Bhopal Zip: 462001 (M.P)
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32335

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

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