Case report| Volume 75, P218-220, May 2020

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Tension pneumocephalus after skull base surgery. A case report and review of literature

Published:April 02, 2020DOI:


      • Tension pneumocephalus is a neurosurgical emergency manifested by headaches, seizures, reduced consciousness and even death.
      • Tension pneumocephalus is a potential complication after skull base surgery.
      • A characteristic finding with tension pneumocephalus on imaging is the Mt. Fuji sign.
      • Accurate diagnosis requires appreciation of imaging features and a high index of suspicion.
      • Prompt intervention is imperative, and definitive management involves repair of the defect allowing intracranial air entry.


      Pneumocephalus describes the presence of air within the cranial cavity and is often self-limiting. Tension pneumocephalus is a neurosurgical emergency manifested by headaches, seizures, reduced consciousness and even death resulting from raised intracranial pressure. Differentiating both entities clinically is often challenging but crucial. We present a case involving a sixty-year-old male who was transferred to our unit after he collapsed while undergoing rehabilitation. The patient had undergone a combined bifrontal craniotomy and transnasal endoscopic resection of recurrent sinonasal adenocarcinoma with anterior skull base involvement eight days prior. Imaging demonstrated the classic Mt. Fuji sign and a diagnosis of tension pneumocephalus was formed. The patient proceeded for definitive management which included a multi-layered repair of the anterior skull base. The three mechanisms that propose the development of tension pneumocephalus include the ball-valve mechanism, the inverted soda-bottle effect and rarely, infection from gas forming organisms. A review of current literature on PubMed/MEDLINE revealed tension pneumocephalus after skull base surgery to be a rare entity with only eleven cases reported. Most patients achieved complete recovery of symptoms post-treatment. Clinicians should recognise tension pneumocephalus as a potential complication after skull base surgery. Accurate diagnosis requires appreciation of imaging features and a high index of suspicion. Prompt management is imperative to prevent possible devastating outcomes.


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        • Greenberg M.S.
        Handbook of neurosurgery.
        8th ed. Thieme, New York2016
        • Ishiwata Y.
        • Fujitsu K.
        • Sekino T.
        • et al.
        Subdural tension pneumocephalus following surgery for chronic subdural hematoma.
        J Neurosurg. 1988; 68: 58-61
        • Yin C.
        • Chen B.Y.
        Tension pneumocephalus from skull base surgery: a case report and review of the literature.
        Surg Neurol Int. 2018; 9: 128
        • Church C.A.
        • Chiu A.G.
        • Vaughan W.C.
        Endoscopic repair of large skull base defects after powered sinus surgery.
        Otolaryngol Head Neck Surg. 2003; 129: 204-209
        • Hong B.
        • Biertz F.
        • Raab P.
        • Scheinichen D.
        • Ertl P.
        • Grosshennig A.
        • et al.
        Normobaric hyperoxia for treatment of pneumocephalus after posterior fossa surgery in the semisitting position: a prospective randomized controlled trial.
        PLoS One. 2015; 10e0125710
        • Clevens R.A.
        • Bradford C.R.
        • Wolf G.T.
        Tension pneumocephalus after endoscopic sinus surgery.
        Ann Otol Rhinol Laryngol. 1994; 103: 235-237
        • Chou S.
        • Ning M.
        • Buonanno F.
        Focal intraparenchymal tension pneumocephalus.
        Neurology. 2006; 67: 1485
        • Ruiz-Juretschke F.
        • Mateo-Sierra O.
        • Iza-Vallejo B.
        • Carrillo-Yague R.
        Intraventricular tension pneumocephalus after transsphenoidal surgery: a case report and literature review.
        Neurocirugia (Astur). 2007; 18: 134-137
        • Emmez H.
        • Durdag E.
        • Uslu S.
        • Pasaoglu A.
        • Ceviker N.
        Intracerebral tension pneumocephalus complicating endoscopic sinus surgery: case report.
        Acta Neurochir (Wien). 2009; 151: 1001-1002
        • Pruss H.
        • Klingebiel R.
        • Endres M.
        Tension pneumocephalus with diplegia and deterioration of consciousness.
        Case Rep Neurol. 2011; 3: 48-49
        • Aksoy F.
        • Dogan R.
        • Ozturan O.
        • Tugrul S.
        • Yildirim Y.S.
        Tension pneumocephalus: an extremely small defect leading to an extremely serious problem.
        Am J Otolaryngol. 2013; 34: 749-752
        • Simmons J.
        • Luks A.M.
        Tension pneumocephalus: an uncommon cause of altered mental status.
        J Emerg Med. 2013; 44: 340-343
        • Mammis A.
        • Agarwal N.
        • Eloy J.A.
        • Liu J.K.
        Intraventricular tension pneumocephalus after endoscopic skull base surgery.
        J Neurol Surg A Cent Eur Neurosurg. 2013; 74: e96-e99
        • Celikoglu E.
        • Hazneci J.
        • Ramazanoglu A.F.
        Tension pneumocephalus causing brain herniation after endoscopic sinus surgery.
        Asian J Neurosurg. 2016; 11: 309-310
        • Iqbal S.M.
        • Khan A.J.
        • Zhi C.
        Tension pneumocephalus: a rare complication of transsphenoidal resection of a pituitary macroadenoma.
        Cureus. 2019; 11e4623