Hellenic Journal of Surgery, 2005, 77, 2 : 585- 590 Tension Pneumocephalus and cervical Pneumorrachis after blunt chest trauma Case Report K.A. Anagnostopoulos, 1 D. Sp. Tsoukalas 1 , Z.C. Fasoulas , E. P. Zagelidou 3 2 Intensive Care Unit General Hospital of Karditsa 1 , Department of Computer tomography G.H. of Karditsa , Forensic medicine Service of Larissa 3 . 2 Corresponding Author: Anagnostopoulos Konstantinos e-mail [email protected]Hellenic Journal of Surgery, 2005, 77, 2 : 585- 590 1
Transcript
Hellenic Journal of Surgery, 2005, 77, 2 : 585- 590 Tension Pneumocephalus and cervical Pneumorrachis after blunt chest trauma Case Report
K.A. Anagnostopoulos, 1 D. Sp. Tsoukalas 1 , Z.C. Fasoulas , E. P.
Zagelidou 3
2
Intensive Care Unit General Hospital of Karditsa1 , Department of
Computer tomography G.H. of Karditsa , Forensic medicine Service of
Abstract We report a case of tension Pneumocephalus with cervical Pneumorrachis of the subarachnoid space and the epidural space, after blunt chest trauma. The coexistence of thoracic-subarachnoid communication with the pneumothorax or the pneumomediastinum is essential for the appearance of this rare complication. In every patient with blunt chest trauma the possible coexistence of traumatic thoracic-subarachnoid communication with the pneumothorax or the pneumomediastinum, must always be seriously considered, in order for the best available mode of intervention to be selected for the patient. Intensive Care Unit General Hospital of Karditsa1 , Department of
Computer tomography G.H. of Karditsa , Forensic medicine Service of
Introduction The intracranial presence of free air is named pneumocephalus.
Neurological dysfunction which is caused by the increasing intracranial pressure of free air characterizes the tension pneumocephalus. The presence of free air in the spinal canal is named pneumorrachis and it can be detected either in the subarachnoid or in the epidural space. Pneumocephalus is a rare, but dangerous complication, which is more frequently evident in intracranial surgical operations or in the case of an open trauma in the cranium. It has however, been reported as a complication in thoracic surgery [6, 7, 11], but also in chest trauma [16], as a result of thoracic-subarachnoid communication. We report a rare case of tension pneumocephalus and cervical pneumorrachis of the subarachnoid and epidural space after blunt chest trauma. A review of literature which includes the pathophysiology, the presentation, the diagnosis as well as the therapeutic choices, are presented. Case Report
A 36 year old male worker was transferred to the emergency room of the General Hospital of Karditsa, with a blunt chest trauma, that was caused by a fallen rock. In the beginning he was diagnosed with respiratory insufficiency, hypovolemic shock and a low level of consciousness, having a Glasgow Coma Scale (GCS) of 12. After the urgent intubation of the patient and the exercise of positive pressures, he expressed sudden neurological deterioration, having a GCS of 6. His ophthalmus initiated paresis (uncoordinated movements of the eyeballs) while his pupils presented automatic alternations of their size (alternately mydriasis and mysis). The status of the patient was initially stabilized with massive fluid administration (crystalloid and colloids) and the bilateral placement of two chest tubes in the thoracic cavity. During the CT – scan, the following investigations were detected: tension pneumocephalus (fig. 1), cervical pneumorrachis of subarachnoid and epidural space (fig. 2), as well as bilateral tension hemopneumothorax, pneumomediastinum, multiple fractures of the ribs and a gap in the thoracic cavity (fig. 3).The patient died during transport to the Intensive Care Unit (I.C.U). The autopsy detected a small fracture of the right anterior cranial fossa, while the dura mater did not present any damage. The brain presented a macroscopic picture of edema. There was no macroscopic damage detected in the parenchyma of the brain and in the cerebellum. The hexagon of Willis was normal. Moreover, the anatomy of the neck did not present any damage. Hellenic Journal of Surgery, 2005, 77, 2 : 585- 590
3
Multiple fractures of the ribs and of the sternum were detected in the chest. The trachea and the main bronchus were unimpaired, while the lungs did suffer multiple punctures and there was an extensive rupture of the parenchyma. The large vessels of the thorax and the heart did not present ruptures. The examination of the vertebral column did not reveal any fractures.
The organs of the abdominal cavity did not present injuries. The death of the patient was attributed to the heavy thoracic injury in combination with severe traumatic brain injury. Taking all of the above into consideration, coupled with the imaging and the findings of the autopsy, we suppose the existence of thoracic- subarachnoid communication. So the puncture and the extensive rupture of pulmonary parenchyma allowed the direct transport of positive pressures that were exercised after the intubation in the intrapleural air. The increase of intrapleural pressure caused the increase of the intracranial pressure, which was expressed with a change of the neurological picture and which probably led to the celebral edema. Discussion
The appearance of pneumocephalus or a combination of pneumocephalus and pneumorrachis after blunt chest trauma presupposes the coexistence of traumatic communication between the subarachnoid space and the thoracic cavity and simultaneously the presence of free air in the thorax. The causes of traumatic communication between the subarachnoid space and the thoracic cavity are usually injury or surgical intervention in the thorax. Lloyd and Sahn (2002) [1], during the examination of all published cases of subarachnoid – pleural fistulas (Subarachnoid-pleural fistula - SPF), found that blunt chest trauma constituted the cause for the creation of traumatic fistulas in 14 of the 30 cases (46%). The trauma (blunt and penetrating) was the cause of traumatic fistulas in 77% of the cases. The other cases are met as complications after transthoracic diskectomy and thorax surgery. As regards to the type of traumatic fistulas, Sarwal et.al (1996) [2], after having studied the published cases of traumatic SPF, found that there are three types of traumatic fistulas:1) The subarachnoid - pleural fistula, which is more common, 2) the subarachnoid - extrapleural fistula and 3) the subarachnoid - mediastinal fistula. These types of traumatic fistulas may coexist. Traumatic fistulas can rarely cause pneumocephalus or even pneumorrachis. Ristagno et.al (2002) [3] report the existence of two published cases where this complication was developed, after blunt chest trauma. The mechanisms with which the traumatic fistulas are created have an immediate relationship with the mechanism of trauma [2]. Blunt trauma, in the
4
case of automobile accidents, is probably due to extreme extension of the spine, resulting in the tearing of relatively immobile thoracic nerve roots and durra. In case that a great amount of compression is exercised above the chest wall, this can lead to the perforation of the pleura against the osteoid ledge of vertebra. This, coupled with tearing of nerve roots, results in the creation of communication. We suppose that this mechanism happened in our patient. Thirdly, sharp fracture of segments of the spine may lacerate both the pleura and the dura mater. The mechanism with which air is transported from the pleural space to the subarachnoid space is not absolutely explicit. The subarachnoid - pleural fistula remains open and allows the exit of cerebrospinal fluid (CSF) because of the presence of pressure gradient that is created by the positive pressure of CSF (50-180 mm H2O) and sub atmospheric (negative) intrapleural pressure, in all of the phases of breathing. The presence of air in the pleural cavity renders the intrapleural pressure less negative and when this exceeds the atmospheric pressure, it causes tension pneumothorax. Under these conditions, it is expected that the transport of air in the subarachnoid space will happen while the intrapleural pressure exceeds the pressure of CSF. The placement of the head in an upright position allows for air to move itself cephalic, resulting in the creation of pneumocephalus. The air, transported via SPF, is mainly distributed in the ventricles and the basilar cisterns of brain [6]. The transport of air in the epidural space of the vertebral column usually happens with two following mechanisms [3]. Atmospheric air passes through a spinal needle into the epidural space. In the other case, if air is present in the posterior mediastinum, it may dissert along fascial planes from the posterior mediastinum (or retropharyngeal space) through nervous foramina, and into the epidural space. Mediastinal air moves into the epidural space behind the driving pressure of a tension pneumothorax or pneumomediastinum. Pneumorrachis of the epidural space by itself is usually innocuous and self-limited [5]. Common symptoms which are detected with the loss of CSF, due to the existence of SPF are headaches, nausea and vomiting [8]. When an increased loss of CSF is detected, disturbances of mental status and symptoms generated by cranial nerves and brain stems, as well as dysfunction of the cerebellum, are observed [9]. The events that are reported in symptomatic pneumocephalus, which is related to the presence of SPF, include headaches and disturbances of the level of consciousness, lethargy and confusion. Finally, focal neurological symptoms, such as hemiplegia, aphasia, gait ataxia and dysmetria may also occur, mimicking a stroke [6], as well as disturbances of eyesight [7]. A high degree of suspicion is required to establish the diagnosis of pneumocephalus. Frequent symptoms due to the intracranial presence of air may be minimal or overshadowed by concomitant injuries and often the diagnosis may be delayed. In each patient with traumatic pneumothorax who
5
presents sudden neurological deterioration, the existence of pneumocephalus should be examined. The diagnosis of pneumocephalus and pneumorrachis is usually very obvious on a CT – scan [14], but it can also be detected with an MRI - scan or even with simple x-rays [3]. The investigation of this rare complication includes the imaging ascertainment of pneumothorax or pneumomediastinum with simple x-rays or a CT - scan and the proof of SPF. The detection of Beta - 2 - tranferrin, with the electrophoresis of pleural fluid is indicative of the presence of CSF and diagnostic for the existence of SPF [4, 10, 11]. In the case of patients with hemopneumothorax, the detection of CSF may be problematic [2]. Definite identification of a fistula is confirmed radiographically. The method of choice to prove SPF is water-soluble myelography that is followed by CT - scanning [1, 2, 6, 13]. This gives information with regards to the location, the length of SPF and the anatomy in the region of lesion. In patients with a low flow of fistula, the radioisotope myelography can confirm the diagnosis, without giving information regarding the anatomy of the region [2, 4, 12]. The treatment of pneumocephalus depends on either the obliteration of the spinal fluid leak or the resolution of pneumothorax. The presence of pneumothorax, the size of the fistulous tract, as well as the time that intervenes until the appearance of the symptoms affect the treatment choices. The removal of free intrathoracic air with the use of suction, so that the reprocess pneumocephalus is achieved, depends on the rate of loss of air. Mc Call, et.al (1986) [16] achieved the reprocess pneumocephalus with the use of suction for the removal of intrathoracic air. Bilsky, et.al. (2001) [6], propose conservative management with bed rest, flat head position and removal of the chest tube from the suction. In the case of patients with a continuous loss of air who needed continuous suction via the chest tube or when SPF remains open for more than two weeks, surgical repair is proposed. There is no consensus for the management of subarachnoid-pleural fistulas. The appropriate timing for surgical intervention is unknown and absolute indications for operation are not clear. Pollack, et.al (1990) [17] propose early surgical intervention for the repair of traumatic fistulas. Sarwal, et.al (1996) [ 2 ] include recurrent and increasing size of CSF flow, persistent symptoms or the removal of a foreign body that causes the S.P.F. as indications for surgical intervention. The last one is considered to be the main indication for emergency surgical intervention. The strategy that indicates spontaneous closure of SPF with decompression of subarachnoid space via closed drainage, with simultaneous presence of pneumothorax is a uncertain practice [6, 9, 15].
6
Pneumocephalus, after blunt chest trauma, is a rare but likely complication. In every patient with blunt chest trauma, the possible coexistence of traumatic thoracic-subarachnoid communication with the pneumothorax or pneumomediastinum, must always be seriously considered, in order for the best available mode of intervention to be selected for the patient.
Special thanks to Dr. Dimitrios Balkizas (Radiologist) for
his useful input and to Mr.Chalatzakos for his technical support.
Hellenic Journal of Surgery, 2005, 77, 2 : 585- 590
7
References
1. Christian Lloyd and Steven A. Sahn Subarachnoid Pleural Fistula Due to Penetrating Trauma Case Report and Review of the Literature. Chest, 2002 , 122 (6) : 2252-2256
6. Mark H. Bilsky, Robert I. Downey, Michael G. Kaplitt
Tension pneumocephalus resulting from iatrogenic subarachnoid pleural fistulae: report of three cases. Ann. Thorac. Surg. 2001 , 71 : 455-457
7. Labadie E.L., Hamilton R.H., Lundell D.C. , Bjelland J.C. Hypoliquorreic headache and pneumocephalus caused by thoraco- subarachnoid Fistula Neurosurgery , 1977 , 27 (10) 993-5
8. Frederick A. Zeller
Pleurodural Fistulas and Neurologic manifestations. Jaber Monla- Hassan and Robert Hyzy Pleurodural Fistulas and Neurologic manifestations (letters) Chest 1999 , 116 (2): 584-5
9. J. Bloch and L. Regli
Brain stem and cerebellar dysfunction after lumbar spinal fluid drainage: case report. J of Neurology Neurosurgery and Psychiatry 2003 , 74: 992-994
10. Frantz P.T. , Battaglini J.W.
Subarachnoid- pleural fistula. Unusual complication of thoracotomy Ann. Thorac. Surg. 1995 , 60 (3): 683-685
11. Reddy H.V. , Queen S. , Prakash D. , Jilaihawi A.N.
Tension pneumocephalus an unusual complication after lung resection: case report. Eur. J. Cardiothorac. Surg. 2003 , 24 (1): 171-3
12. P. Fernandez, M. Goyot. P. Mangione et. Al.
Subarachnoid – pleural Fistula complicating thoracoscopy. Value of In- 111 DTPA myeloscintigraphy
8
Clin.Nucl. Med. 1999 , 24: 985-986
13. Rana Sandip Singh, Ashis Pathak Tension pneumocephalus after excision of posterior mediastinal mass Ann. Thor. Surg. 1999 68 (2): 366-368
14. MB Lin, FK Cheah, SE Ng, TT Yeo Tension pneumocephalus and Pneumorrhachis secondary to Subarachnoid pleural fistula Br. J. of Radiology, 2000, 73 : 325-327
15. S.H. Kitchel, FJ Eismont and B.A. Green Closed subarachnoid drainage for management of cerebrospinal fluid leakage after an operation of Spine. J of Bone and Joint Surg. 1989 , 71 (7): 984-7
16. Mc Call CS , Nguyen T Q , Vines FS , Bremeu AM
Pneumocephalus secondary to tension pneumothorax associated with comminuted fracture of the thoracic spine Neurosurgery 1986 , 19 (1) : 120-2
Fig. 1: Axial non-contrast CT-scan of the head at the level of lateral ventricles demonstrating: Air in the subarachnoid space of the frontal lobes, as well as air in the frontal horns of the lateral ventricles, under tendency (alteration of the physiologic convexity of lateral ventricles). Tension pneumocephalus.
10
Fig. 2: CT-scan of the neck at the level of larynx demonstrating: Air in the spaces of the neck, as well as air in the retropharyngeal space. In the same section, air in the subarachnoid space of cervical spinal canal and air inside of the epidural fat. Pneumorrachis of the subarachnoid space and the epidural space.
11
Fig. 3: CT-scan of the thorax (pulmonal window) demonstrating: Subcutaneous and intramuscular emphysema of thoracic wall. Bilateral tension hemopneumothorax and pneumomediastinum.
