#Pneumocephalus

[jcrmhscasereports]

Delayed onset of intracerebral tension pneumocephalus 2 years after an anterior skull base fracture: Case report by Sokchan Sim in Journal of Clinical Case Reports Medical Images and Health Sciences

ABSTRACT

Pneumocephalus, the presence of air within the cranial cavity, is most commonly caused by trauma, tumor, infection and fistulation into the intracranial cavity or secondary to neurosurgery. We describe an unusually delayed neurological deficit from intracerebral tension pneumocephalus, 2 years following a head trauma with anterior skull base fracture. A 22-year-old man presented to our neurosurgical consultation with recurrent seizures and progressive right hemiparesis. The brain CT scan without iv contrast revealed an intracerebral tension pneumocephalus in the left frontal lobe, and a persistent hole in the left anterior frontal skull base connecting to pneumocephalus. We performed a left frontal craniotomy, and dura-plasty using galea flap to cover the skull-base bone defect. The patient has recovered gradually from his motor deficit after this surgery, finally to the level that he could play his favorite guitar. This is a rare case of a delayed development neurological deficit due to pneumocephalus from a “ball-valve” effect secondary to an old anterior skull base fracture.

Key words: Pneumocephalus, hemiparesis, craniotomy, dura-plasty

INTRODUCTION

Pneumocephalus is an air entrapment in the cranial cavity. It is commonly seen after head and facial trauma, ear infections, and tumors of the skull base or neurosurgical interventions. In some extremely rare cases, it happens spontaneously. Pneumocephalus is a complication of head injury in 3.9–9.7% of the cases. The accumulation of intracranial air can be acute (<72 h) or delayed (≥72 h). In tension pneumocephalus, the continuous accumulation of intracranial air is thought to be caused by a “ball-valve” mechanism. In turn, this may lead to a mass effect on the brain, with subsequent neurological deterioration and signs of herniation. Delayed tension pneumocephalus is extremely rare and requires proper neurosurgical attention. Surgical treatment involves aspiration of air into a syringe and closure of the dura defect through a cranial surgery.

CASE REPORT

A 22-year-old male presented to our neurosurgical consultation with chronic headaches, progressive right-sided weakness and occasional seizures. Two years prior to this visit, he suffered a severe traumatic brain injury by motorcycle accident. He had lost his consciousness for three days, and hospitalized in a provincial hospital for two weeks without any surgical intervention. He was then discharged home with persistent rhinorrhea for 10 months before it ceased spontaneously. 18 months after his injury, this patient began having progressive weakness on his right side of the body, and some episodes of seizures. He also reported occasional headaches.  He was otherwise healthy before this accident. On examination, the young man had full consciousness, was alert and oriented. He had grade 3 out of 5 hemiparesis on his right side. A brain CT scan without iv contrast was obtained revealing a large pneumocephalus in the left frontal lobe. We noted a continuity of the air and the anterior skull base defect. (Figure.1)

CSF examination and culture were negative for infection, as well as the nasal swab.

Figure 1: A. Axial view of the CT scan showing hypodensity area in the left frontal lobe, pneumocephalus. B. Sagittal view presenting the large air space with its connection to the frontal skull base. C. Coronal view showing the bony defect of the anterior skull base.

We decided to perform the surgery by doing bi-coronal approach for a left frontal craniotomy and repair of the dura defect on the frontal skull base using the pedunculated galea flap. (Figure.2)

Figure 2 :A. Bi-coronal incision with preservation of large frontal galea. B. Galea still attached to the frontal base is lifted up.

The surgery went well without any complication. The post-operative course was without any significant event. No sign of infection was noticed. The patient recovered gradually from his motor deficit on his right side. The post-operative CT scan showed complete resorption of the intracerebral pneumocephalus. (Figure.3). Intravenous prophylactic antibiotics were used to prevent meningitis.

Figure 3: Post-operative CT scan showing no hypodensity area in the left frontal lobe, complete disappearance of the pneumocephalus A. Axial view B. Sagittal view C. Coronal view. Noted the small bone defect from craniotomy site.

At one-month follow-up, his motor function on the right body became normal that he could play his favorite guitar again. At three-month follow up, he had an episode of new seizures, we controlled his seizures with anti-epileptic drugs for two years afterward.

DISCUSSION

The term “pneumocephalus” was first coined more than one century ago by Luckett and Wolff independently. The term “tension pneumocephalus” was proposed by Ectors, Kessler, and Stern in 1962. Pneumocephalus or also known as pneumatocele or intracranial aerocele is defined as the presence of air in the epidural, subdural, or subarachnoid space, within the brain parenchyma or ventricular cavities. It is a complication of head injury in 3.9 – 9.7% cases. It also appears after supratentorial craniotomy surgery. The accumulation of intracranial air can be acute, less than 72 hours, or delayed, more than 72 hours.

Two mechanisms have been proposed to explain pneumocephalus. In the first mechanism, the pathophysiologic process starts with Cerebro-Spinal Fluid (CSF) leak in the presence of associated discontinuity of the cranium and leptomeningeal disruption. Subsequent development of relative negative Intra-cranial Pressure (ICP) results in a sufficient “vacuum effect” to cause additional accumulation of air within the cranial cavity. This air is generally distributed in the subarachnoid space. The second mechanism is based on the presence of a “one-way valve” at the site of the leptomeningeal tear. In this case, we found on the CT scan images a bone and dura defect in the left anterior skull base, in connection with intracerebral air collection. The air went in, and was trapped inside the frontal cerebral parenchyma. Slowly it became larger and more significant, putting mass effect into the brain tissue of the patient’s frontal lobe. The patient had experienced rhinorrhea (CSF leak through the nose) after the head trauma but disappeared spontaneously after 10 months. He then developed right hemiparesis and experienced episodes of seizures. Recurrent headaches were also a main complaint. These signs and symptoms were described in previous reports about tension pneumocephalus.

The diagnostic imaging for pneumocephalus is CT scan. “Mount Fuji sign” is described when there are bilateral hypoattenuation collections, causing compression and separation of the frontal lobes on CT scan. In our case, an intraparenchymal air-filled long cavity was seen in the left frontal lobe, with its tip connecting to the frontal skull base.

Most cases of pneumocephalus tend to resolve spontaneously with conservative management. Nonoperative management involves oxygen therapy, maintaining the patient supine or in Trendelenburg position, prophylactic antimicrobial therapy (especially in posttraumatic cases), adequate analgesia, frequent neurologic checks, and repeated CT scans. The use of continuous high concentration inspired oxygen as a treatment modality for traumatic pneumocephalus may have certain theoretical benefits. Prompt decompression of intracranial air is the initial treatment of symptomatic pneumocephalus. The principles of subsequent treatment parallel those for a CSF leak. It is important to identify the site where the communication between the air cavity and the external environment occurs. If the site can be identified, the passage should be sealed off, thereby decreasing the possibility of worsening or recurrent pneumocephalus. Effective therapy of tension pneumocephalus through a controlled decompression using a closed water-seal drainage system has also been described. In our case, we performed a full scale left frontal craniotomy to evacuate air from the intraparenchymal cavity, closure of the skull base defect by using pedunculated galea flap, re-enforced by bio-glue as a sealing material.

CONCLUSION

Tension pneumocephalus is a life-threatening neurosurgical case. Although the development of this massive intracerebral air trap was delayed in this case, it caused significant neurological deficit. The patients who suffer from head trauma, with CSF leak should be subject for long term follow up.

Disclosure: Nothing to disclose, and there was no conflict of interest among the authors.

Research ethics: Informed consent has been obtained from the patient.

For more information: https://jmedcasereportsimages.org/about-us/

For more submission : https://jmedcasereportsimages.org/

[centre-forbrainandspine]

Cerebrospinal Fluid Leak Symptoms and Treatment in Dwarka, Delhi

Ever experienced throbbing head pain accompanied by nausea and neck stiffness? These could be signs of a Cerebrospinal Fluid (CSF) leak, a condition where the fluid surrounding your brain and spinal cord escapes through a hole in the connective tissues. Causes range from injuries to medical procedures like lumbar punctures or epidurals, and sometimes, the cause remains elusive. The good news? Most cases resolve on their own within days, with no long-term issues. However, persistent symptoms may require mending the tear in the connective tissue. Below, a top Neurosurgeon in Delhi explains the symptoms, causes, and treatment of Cerebrospinal Fluid (CSF) leaks sharing about this condition in-depth. Read on.

What is a spinal fluid leak?

A spinal fluid leak occurs when there’s a hole in the protective layers surrounding the brain and spinal cord, known as meninges. These layers hold the cerebrospinal fluid (CSF), vital for flushing out contaminants, transporting nutrients, and cushioning the brain and spinal cord.

The outermost layer, the dura mater, is a tough tissue responsible for maintaining CSF within the meninges. However, if a breach occurs, CSF escapes, leading to symptoms like headaches, nausea, and neck stiffness. While most cases resolve without severe complications, in rare instances, a spinal fluid leak can lead to serious outcomes such as stroke, coma, or even death.

Symptoms of a spinal fluid leak

Persistent head pain might be a symptom of a Cerebrospinal Fluid (CSF) leak. However, not everyone with a leak will have this symptom. The pain is often positional, intensifying when upright and easing when lying down. Typically located at the back of the head, it can vary in severity and location.

Other common symptoms include:

Nausea and vomiting

Neck pain or stiffness

Imbalance

Sensitivity to light or sound

Changes in hearing

Pain between shoulder blades

Arm numbness or pain

Dizziness

Altered thinking, akin to brain fog

Changes in vision or taste

Fatigue

Facial pain or numbness

Causes of spinal fluid leak

The causes of a spinal fluid leak can vary. They often originate from incidents or medical procedures affecting the protective layers around your brain and spinal cord. Some common causes of spinal fluid leak are:

Trauma: Accidents or injuries, such as a severe blow to the head or spine, can create a breach in the protective tissues, leading to a leak.

Medical Procedures: Invasive medical procedures like lumbar punctures, spinal surgeries, or epidural injections may result in a tear in the connective tissues.

Spontaneous Leaks: In some cases, a spinal fluid leak can occur spontaneously without an apparent cause.

Risk factors associated

Certain factors can increase the chances of experiencing a Cerebrospinal Fluid (CSF) leak, either in the spine or the cranial region.

Risk factors for spinal CSF leaks include:

Previous spine surgery or procedures.

Conditions like Marfan syndrome or Ehlers-Danlos syndrome, affect connective tissues and may lead to joint hypermobility and dislocations.

For cranial CSF leaks, risk factors may include:

Prior skull surgeries.

Obstructive sleep apnea.

Head trauma.

Presence of a tumour at the skull base.

Irregularities of the inner ear or skull base.

Complications

Complications may arise if a cranial CSF leak remains untreated. Neglecting the issue can potentially lead to serious problems, such as meningitis, and an inflammation of the membranes surrounding the brain. Another concern is tension pneumocephalus, a condition where air enters the spaces around the brain, posing a risk to neurological well-being.

On the spinal front, untreated CSF leaks could result in subdural hematomas, characterised by bleeding on the brain’s surface. While some CSF leaks often resolve on their own, seeking medical attention from a medical professional can prevent these complications, leading to a smoother recovery process.

Diagnosis of Cerebrospinal Fluid Issue in Dwarka

If a Cerebrospinal Fluid (CSF) leak is suspected, your doctor may suggest several tests to pinpoint the issue accurately.

Analysis of Nasal Fluid: This test detects beta-2 transferrin, a protein mainly found in CSF.

CT Scan: It is a non-invasive procedure utilising X-rays and advanced computer technology to generate detailed images of the brain’s structure.

MRI Scan: This imaging technique uses magnets and radio frequencies to provide detailed organ and structure images. It helps in locating and assessing CSF leaks.

Cisternogram — CT or Nuclear Medicine: These tests involve a spinal tap to introduce a fluid into the CSF, helping identify the presence and source of a CSF leak.

CT Cisternogram: It pinpoints the site of a CSF leak, using a contrast medium and a spinal tap followed by a CT scan.

Pledget Study: It confirms CSF leakage into the nose or mastoid by injecting a radioactive tracer during a spinal tap, with cotton pads collecting fluid for analysis.

Myelogram Scan: This involves injecting a contrasting substance into the spinal cord while utilising MRI or CT scans to identify tears or ruptures in the dura.

CSF leaks treatment in Dwarka, Delhi

Treatment for CSF leaks is important, especially for patients with persistent symptoms. Repairing tears in the dura promptly reduces headache pain and lowers the risk of meningitis.

Nasal CSF Leak: Endoscopic nasal CSF leak closure is done through the nostrils. It repairs the leak using nasal tissue or a biomaterial graft. Hospital stay duration depends on the leak’s size, typically a few days. Some may require a lumbar drain before discharge.

Ear CSF Leak: This closure involves a skin incision behind the ear, accessing the leak near the mastoid. The opening is sealed by repairing with tissue or a graft.

Spinal CSF Leak: This treatment involves when blood or fibrin patches are injected into the spinal canal under CT guidance. If unsuccessful, duraplasty, or surgical repair of the dura, might be required.

The outlook for those experiencing a Cerebrospinal Fluid (CSF) leak is generally positive, depending on the underlying cause. Fortunately, in most cases, the issue resolves with no lasting symptoms.  However, recurring CSF leaks could signal a potential concern—high CSF pressure (hydrocephalus). It’s crucial to address this condition with the help of a neuro doctor in Dwarka promptly. Regular monitoring and medical guidance are key to ensuring a favourable outlook and preventing recurrent leaks. In cases where hydrocephalus is diagnosed, targeted interventions are important for the patient’s well-being.

[mri-radiology-blog]

Симптом #Гора #Фудзи 🇺🇸👇 Визуализируется на аксиальных изображениях и подразумевает напряженную #пневмоцефалию 🇺🇸👇#Mount Fuji sign. Mount Fuji sign is seen on cross sectional imaging and implies tension #pneumocephalus is present. by Dr Chris O'Donnell et al. #radiopaedia #MountFujisign - ---------- 👇Comments please🤝👍🙏 ----------

[iluxia]

Another fun scan! This CT shows hydrocephalus with a clearly demarcated pneumocephalus (air in the brain, the black section above the line of CSF) - rather unusual and definitely livened up our otherwise droll evening. Gravity still has its hold within the body; this patient was laying on their back in the CT scanner (head slightly tilted due to neck mobility issues) and correspondingly the cerebrospinal fluid has collected down towards the back of the head while the air rose to the top. This patient had severe headaches affected by positioning and breathing.

That bright white blip in the middle of the enlarged ventricles is the tip of a ventriculostomy, a long thin tube we drill through the skull into the brain to terminate within a ventricle for the diversion of CSF and/or blood. It also gives us a very accurate reading of intracranial pressure in cmH2O. A ventriculostomy is the quick fix to acute-onset hydrocephalus; a ventriculoperitoneal shunt (VP shunt) is a more permanent solution for patients who live with congenital or symptomatic normal pressure hydrocephalus (NPH).

All of these interventions are centered around the Monro-Kellie hypothesis, a basic concept of neuroscience. Within the brain, there are only brain, blood, and cerebrospinal fluid. Given that they are all confined within the inflexible bone cage of the human skull, logic dictates that an overabundance of one of these three substances leads to increased intracranial pressure (ICP). An overabundance of brain tissue would be a tumor, for example, and an overabundance of CSF is hydrocephalus due to inefficient drainage and/or reabsorption of the fluid. An overabundance of blood would be if an aneurysm popped and bled into the brain tissue, causing a hemorrhagic stroke and subsequent edema. Therefore it follows that in order to correct the pressure, we must then relieve the overabundance or increase the space. Hence we place a ventriculostomy to drain excess CSF out, or break the skull open (craniotomy) and excise a tumor, or temporarily remove a piece of the skull (hemicraniectomy) to allow the brain some space to swell as it recovers from a massive stroke.

[didanawisgi]

Abstract—Although data from the PEAR program at Princeton University appear to support a role for intentionality in determining physical phenomena, the use of theoretically based controls raises concerns about validity of the findings. We re-examined claims from the PEAR lab using experimentally derived control data in a study of patients with frontal lobe brain damage and normalsubjects.The rationale for includingfrontal patientsfollows a suggestion that reduced self-awareness may facilitate effects of intentionality on physical phenomena. Frontal patients may have reduced self-awareness, a state not easily achieved by normal subjects, and may provide a good model for studying the role of consciousness on physical events within a conceptual framework that maximizes the likelihood of detecting possible effects. We found a significant effect of intentionality on random physical phenomena in a patient with left frontal damage that was directed contralateral to his lesion. Moreover, the effect was replicated. Keywords: consciousness—self-awareness—intentionality—frontal lobe damage—random event generator

Although several studies claim to support a role for intentionality in determining physical phenomena (Schmidt, 1969; Schmidt & Pantas, 1972; Jahn & Dunne, 1987a; Radin & Nelson, 1989; Jahn et al., 1997), concerns about research design and a lack of theoretical models (Alcock, 1987; Jeffers, in press), as well as negative studies (Hall et al., 1977; Jeffers & Sloan, 1992; Ibison & Jeffers, 1998), have been important sources of criticism of the literature in this area. A major methodological problem in research design relates to the issue of inadequate experimental controls (Jeffers, in press). For example, Robert Jahn and his colleagues from the Princeton Engineering Anomalies Research (PEAR) programhave reported statisticallysignificanteffectswhereby subjects,or‘‘operators’’, have successfully influenced the statistical distribution of outcomes from a Random Event Generator (REG) (Jahn et al., 1987a; Jahn et al., 1997). A concern relates to the nature of the machine calibration data used for comparison to subject generated data (Jeffers, in press). Rather than collecting control data in close temporal proximity to the period when a subject is trying to influence the REG output, the PEAR protocol relies on the assumption that the REG output is always random in the absence of operator influence. This approach does not control for potentially unrecognised factors that may affect the REG output and therefore casts doubt on the interpretation of the experimental findings. In addition, there are theoretical issues raising questions about the findingsfrom Jahn’s group,such as the independence of the reported effects from time and distance, that are difficult to reconcile (Jahn et al., 1997; Jeffers, in press). Nevertheless, Jahn and his colleagues have amassed a great wealth of data to support their conclusionsthat an individual’s conscious intention can alter the statistical distribution of random physical phenomena. Because their findings would have immense significance if validated, we re-examined their claims using a methodology with well-designed control conditions. Some highly interesting but speculative ideas relating anomalous physical activity to consciousness have been advanced by Jahn and Dunne (Jahn et al., 1987a; Jahn & Dunne, 1986). They proposed a metaphor for consciousness based upon quantum mechanical concepts that relates consciousness to anomalous physical phenomena. Based on data from the PEAR lab, they suggest that consciousness has the potential to influence random physical events and that this effect is maximal when consciousness is exhibiting ‘‘wave properties’’ rather than ‘‘particle’’ properties. Although it is unclear how consciousness can be characterised in physical terms, the analogy has interesting implications when taken a step further. Jahn and Dunne propose that the wave properties of consciousness correlate best with a state in which individuals are able to divert their attention away from their self-awareness in relation to events around them. This analogy suggests that states of reduced self-awareness may facilitate the effects of consciousness on physical phenomena. Self-awareness is a highly complex neurological function comprised of several hierarchical levels ranging from visceral knowledge to more abstract concepts ofself-image. There is a well-establishedliterature suggestingthat thisfunction is mediated by the frontal lobes and that frontal lesions are associated with reduced self-awareness (Stuss & Benson, 1986; Stuss, 1991; Carver & Scheier, 1991), a state that is not easily achievable by normal individuals.Studying patientswith frontal lobe lesions may provide a good model for testing the hypotheses from the PEAR lab within the context of a conceptual framework that would maximise the likelihood of detecting effects, if these in fact exist. We report our findings in patients with frontal lobe lesions and in normal subjects, as well as replication data in one subject with left frontal brain damage.

Discussion 

We examined the claims from the PEAR program that an individual’s intentions can influence the statistical distribution of random physical phenomena. Our main focus was to test these claims using well-designed control conditions in a population that might maximize the likelihood of detecting any effects that may exist. Our choice of studying patients with frontal lobe lesions was based on the concept that the potential to influence random physical events may be optimized when attention is diverted from self-awareness (i.e., such as when self-awareness is reduced). This state can occur following frontal brain damage (Stuss et al., 1986; Stuss, 1991; Carver et al., 1991). Our findings showed a significant effect for the right intention in a subject with left frontal brain damage. Moreover, this effect was in the direction of intention. In contrast, there were no significant effects in the other groups (i.e., bilateral frontal, right frontal, pooled frontal, or normal subjects). Although the result in the left frontal patient on the right intention was statistically significant, even after correction for multiple comparisons, this finding was interpreted with great caution. First, it was based on a relatively small number of intention trials (n ˆ 3,000) and was derived from only one subject. Second, we found a p-value for an individual ‘‘subject’’ in the pseudodata that would also have met criteria for significance using a Bonferroni correction and that was even less than the p-value of 0.0015 obtained from the left frontal subject. Although the effect of this ‘‘pseudopatient’’ was not in the direction of intention, the fact that it was significant raised caution for interpreting the effect in the left frontal patient. However, the replication of the findings in the left frontal patient in a second well-designed study for each of the three intentions: right, left, and baseline, suggests that the effect in this subject may be more than chance occurrence. Additional support for a reliable effect in the left frontal subject comes from further analysis of his data suggesting about a 94% chance of his showing a similar finding if another series of 19 pairs of blocks of 1,000 trials were run again. Furthermore, the profile of REG output data for the right intention showed a fairly consistent separation whereas this was not the case for the left or baseline intentions. A comment is warranted about the REG output for the left frontal patient being lower for the control condition on the right intention, or more to the left, as compared to the control conditions for the left or baseline intentions. One might argue that the significant effect on the right intention was an artifact of comparison to control data that was in the left direction and that this widened the difference between the intention and control data. However, this argument is not tenable because the effect on the right intention was significant even when the REG output was compared to a theoretical mean of 100—a value which is approximately equal to the control means for the left intention (99.99985) and the baseline intention (100.0011). The patient’s cognitive deficits and brain lesion have been described elsewhere (Marras et al., 1998). He suffered from a tension pneumocephalus which resulted in cognitive deficits and epileptic seizures. The cognitive deficits include decreased mental flexibility on the Trail-Making Test, poor attention, reduced fluency, and impaired spatial planning and visuospatial problem solving. MRI showed an extensive left frontal lesion but the right frontal lobe was intact. Psychometric testing and SPECT suggested the addition of right frontal dysfunction. The SPECT findings provide a measure of function, as opposed to structure, and were subtle. As indicated above, frontal lesions have been associated with reduced selfawareness (Stuss et al., 1986; Stuss, 1991; Carver et al., 1991), a state that is difficult for normal individuals to achieve. The rationale for studying patients with damage to the frontal lobes was that decreased self-awareness might facilitate the effects of intentionality on random physical phenomena. Brain regions that mediate neurological processes underlying self-awareness include the frontal lobes bilaterally, particularly on the right (Stuss et al. 2001a; Stuss & Alexander, 2000a; Stuss & Alexander, 2000b; Stuss et al., 2001b). Whereas the patient’s right-sided brain dysfunction may have been insufficient to produce a deficit in self-awareness, the extensive lesion on the left may have resulted in reduced self-awareness when attention was directed towards the right. However, it remains unclear why positive results should be found only following damage to the left frontal region and not after bilateral or right frontal lesions. One speculation is that the effect on random physical events may require reduced self-awareness combined with relatively intact attentional mechanisms. The association of frontal lobe lesions, especially on the right, with impaired attention (Stuss & Levine, 2002) may explain the negative findings in the setting of bilateral or right frontal damage. Whether deficits related to left frontal abnormalities can explain the observed effects on the REG output warrants further study. Moreover, the question whether normal processes associated with intact frontal lobe function, together with preserved self-awareness, may serve to inhibit effects of intentionality on random physical phenomena needs to be addressed. The strength of our conclusions rests largely on a well-designed methodology and replication of our findings. Although our results did not replicate the findings reported by Jahn and his colleagues in normal subjects (Jahn et al., 1987a, 1997), they support their claims that intentionality can alter the output of a random event generator. Furthermore, our findings suggest that patients with frontal lobe lesions may serve as a good model for future studies of the effects of consciousness on random physical events.

[jaarhealthcare]

How Nursing Care Ease The Comfort For Neurological Patients

A principle goal for people with long-term neurological disabilities, whether conservative or progressive, is to live as long as possible an active life in the community. These patients' neurological management aims to reduce their impairment and consequent disability within society. Access to information, advice, and therapies from qualified health professionals, therapy, accommodation, provision of aids and equipment, personal assistance, transportation, and access to community are the most basic requirements to enable independent living with

Nursing Care For Neurosurgery Patient

.

Why Neurosurgery Patients Need Nursing Care?

Nursing Care by neurology-trained, intensive care physicians and staff have proven advantageous in minimizing in-hospital mortality and stay durability. Following surgery, neurological complications include focal deficits from cerebral neuropathy, intracranial hemorrhage, seizures, stroke, pneumocephalus and leaks of cerebrospinal fluid.

Postoperative Management for Neurosurgery includes:

Keep the head of the bed at thirty degrees to reduce intracranial pressure.

Maintain normal body temperatures.

Monitor swelling of the brain.

Complete frequent checks of overall skin integrity and surgical site status.

Monitor intake and output of fluids, drainage, and secretions.

Monitor respiratory status and encourage coughing and deep breathing; perform chest percussion to loosen secretions if warranted.

Control pain of the patient.

Do a passive range of motion exercises to keep the patient's joints and muscles strong.

In postoperative patients will require only 12-24 hours of ICU-level monitoring and can then be discharged to the general floor. The detect and intervene on the problem will directly affect the recovery and the level of function the patient achieves in recovery. Also to be considered is the pre-operative level of function and the underlying clinical condition for Patients.

[neurocirurgiabr]

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A post shared by Julio Pereira Neurocirurgiabr (@neurocirurgiabr)

Post op coronal Brain CT of Stereotactic right posterior parietal craniotomy and excision of tumour. #Repost @spinesurgeon Day 15 of 30 days on-call straight series: Tumour has been completely resected. Some pneumocephalus. Patient woke up alert and orientated with no left sided dyspraxias and resolution of her alien hand syndrome. #neurosurgery #brain #braintumor #tumor #surgery #operation #hospital

[clinicalsurgery]

Osteo-Meningeal Breaches of the Anterior Floor of the Skull Base: Mini Review in Open Access Journal of Medical and Clinical Surgery by El Bouhmadi Khadija*

Abstract

Osteo-meningeal breaches of the anterior floor of the skull base are a solution of continuity between the meningeal and underneath bony structures. They can be primary or secondary, usually post traumatic or iatrogenic. The main clinical manifestations are rhino-liquorrhea and recurrent meningitis. Radiological investigations are highly contributory by exposing the defect and assessing the herniated content. Optimal treatment depends on the breach parameters and the consequent hernia. Surgery, when indicated, consists on the exposure of the defect and its clogging using different grafts. Endoscopic endonasal approach remains the most currently practiced regarding its aesthetic benefit and conclusive results.

Introduction

The anterior floor skull base osteo-meningeal breaches (OMB) are a solution of the osteo-meningeal continuity producing leakage of cerebrospinal fluid (CSF) through the defect into the contiguous air-filled cavities of the face [1,2]. Its incidence varies from 4.6 to 7.6 cases per year in the US in 2004 and 9 cases per year in Belgium in 2008 [3,4].

Circumstances of Occurrence

The osteo-meningeal breaches can occur at any site but they are more likely seen in the fragile anatomical points. The weak areas in the bone are the ethmoid cribriform plate regarding its perforated and aerated constitution, the facial sinuses (frontal and sphenoidal) specifically when hyperpneumatized with thinned walls and the skull base foramens and ledges [1,2]. In the meninges, the weakest areas are paradoxically the areas of their adherence to the skull base [2].

The OMB in the anterior floor of the skull base can be primary or secondary. Secondary OMB are the main clinical presentation (96%) posttraumatic in 90% of the cases and iatrogenic postoperative in 10%. Following an accidental skull base trauma, tearing or shearing of the dura from its adherences can be caused by acceleration deceleration mechanisms of force. Then, the breach gets maintained by the communicating hydrocephalia. On another hand, CSF leakage represents 66% of endoscopic nasal surgery complications favoured by the surgeon inexperience, the surgical revision but also the predisposing anatomy like asymmetric position of the ethmoid roof and Crista Galli pneumatisation. Also, progressive lysis of the bone causing OMB can be secondary to pituitary or nasal tumors or inflammatory and septic processes such as skull base osteomyelitis or fungal sinusitis [1]. The most affected sites are the sphenoid sinus with a highest risk for the anterior ethmoidal roof than the posterior [2].

Primary or spontaneous breaches define CSF leakage unrelated to trauma, surgery, tumor, or previous radiation therapy [5]. Representing 3-4% of OMB [2], they are a diagnosis of exclusion [1]. The bony erosion is the mechanical consequence of the chronic and perpetual contact between the pulsatile meninges and the bone in addition to the imbibition phenomenon. They get divided according to intracranial CSF pressure. OMB with normal CSF pressure are usually related to congenital malformative defects of the skull base, meningocele or meningocephalocele, or hyperpneumatization of the lateral walls of the sphenoid sinus. OMB with intracranial hypertension can be associated to cerebral aqueduct stenosis or an empty sella. The hypertension leads to slow erosion of the spheno-ethmoidal roof and a dehiscence of the sellar floor. Unlike secondary OBM, they usually affect the frontal and ethmoid sinuses and the nasal fossa and rarely the sphenoid sinus [2]. Also, primary OBM are more likely to be bilateral and multiple [5].

Clinical Presentation

The main clinical presentation of OMB of the skull base anterior floor is rhino-liquorrhea and recurrent meningitis. Headaches, nasal obstruction and olfactory troubles can also be reported [2]. The rhino-liquorrhea is described as nasal leakage usually unilateral, intermittent, sometimes abundant, of a colorless salty liquid clear as rock water [1]. Active or inactive, it can be positional and provoked by an antepulsion or genupectoral position, or also by coughing or by Valsalva maneuver. History of facial trauma or nasal endoscopic surgery should be reported. The liquorrhea can appear years after the incident when the natural fibrous scarring ruptures by a minor trauma or an increasing of intracranial pressure [2].

Conventional biochemical analyses of the liquid find increased protein or glucose. Glucose concentrations greater than 0.3 g/L and protein concentrations up to 2 g/L are considered indicative of CSF [6]. But, the necessity of large samples, the contamination in the event of blood and the rate of false positive up to 45-75% are important disadvantages [6,7]. However, even if the determination by glucose test strips in bedside secretions has low sensitivity and specificity, it can be useful in the emergency room [7].

The most specific indicator is the presence of beta2transferrine in the nasal leakage, since it is found almost exclusively in CSF. Only a few other body fluids, such as the cochlear perilymph and the aqueous and vitreous humor of the eye, contain also low concentrations. The initial method was first described in 1979, largely improved today using a method of isoelectric focusing in a highly standardized fashion giving the results within 3.5 to 8 hours with a specificity of 99% and a sensitivity of 97% [6]. Easy and non-invasive, this method is particularly contributing when the leakage is sparse or intermittent [2].

The OMB can also be revealed by nervous system septic complications such as inaugural or recurrent pyogenes meningitis or meningoencephalitis with the Streptoccocus Pneumoniae as the most incriminated germ, cerebral abscess, empyema, cerebral vein thrombosis or osteitis [1,2]. The high incidence of bacterial meningitis indicates prophylactic antibiotic waiting for surgery [8].

Radiological Findings

The main aim of radiological investigations is to confirm the presence of an OMB, specifying its location and eventually, its underlying cause. Cranio-facial CT scan, preferably performed after provocative maneuvers, allows the exploration of the anterior and middle floors of the skull base. The sections are made on fontal and axial planes [2]. It shows a bony solution of continuity between the meningeal structures and the sinuses or the nasal fossa specifying its location and thickness, with hydroaeric level or epidural, subdural or subarachnoidian pneumocephalus realising in its massive form the Mount Fuji sign (air between the tips of the frontal lobes [1].  An opacity can be observed in the airy cavity corresponding to SCF or herniated cerebral tissue [2].

The MRI reveals T2 hyperintense signal between the subarachnoidian spaces and the sinuses or the nasal fossa interrupting the hypointensity of the bone. With an estimated sensitivity between 80 and 93,6% and positive predictive value between 92 and 100%, [2] it can confirm the presence of the OMB even without active nasal leakage. However, few false positive results can be related to post trauma or postoperative fibrosis, the presence of sinusitis or mucocele [1].

The association of CT scan and MRI is the first line imaging investigation, increasing slightly their sensitivity to 95% but majorly their specificity that reaches 100% [2]. In second intention, the invasive MRI with intratechal injection of Gadolinium through lumbar puncture allows better differentiation between facial sinuses, cerebral tissue and CSF spaces by increasing the signal intensity in the cisterns and ventricules [1]. CT cisternography comes in third line since it’s an invasive procedure that should only be considered when the diagnosis remains uncertain following CT scan and MRI [2].  Comparison of images taken in different positions helps the detection of positional rhino-liquorrhea. Isotopic cisternography using technetium or indium is practically not used anymore, even with good sensitivity for small and intermittent fistulae; its spatial resolution is so mediocre that its localisation value is very poor [1].

Bases of Treatment

The therapeutic management of OMB must consider the cause, the anatomic site, the size of the defect, the age of the patient and the underlying intracranial pressure [7].  In the secondary forms of OMB, the treatment of the etiology is mandatory while the breach closing alone is enough for primary OMB [1].

The medical treatment is proposed when the OMB is minimal in order to favour spontaneous scarring. It is based on rest, repetitive lumbar punctures and draining and drugs like diuretics and carbonic anhydrase inhibitors (CAI) [2].  The CAI decrease the rate of formation of H+ and HCO3- within the blood-brain barrier. These ions are usually exchanged for plasma anions and cations, largely Na+ and Cl-, which thus enter the interstitial fluid followed by the entrance of water to maintain osmotic equilibrium. This mechanism is considered to exist not only in the choroid plexus but throughout the central nervous system parenchymal vasculature. And then, the rate of formation of interstitial fluid and cerebrospinal fluid diminish resulting in a marked reduction in intracranial pressure [9].

The actual guidelines from the “French National Authority for Health” (after revision in 2017) concerning Pneumococcal vaccination include patients with OMB as non-immunosuppressed patients with underlying disease predisposing to invasive Pneumococcal infection [10]. The surgical indications are abundant liquorrhea and/or persistent despite medical treatment, recurrent septic complications and multiple and bilateral OMB [2]. In order to visualize the OMB path during surgery, mostly whit non-contributory imaging, an intratechal injection of 0,5% Fluorescein can be performed before starting the procedure. The colorant well distributed with Trendelenburg position infiltrates and exposes the breach. However, it has a high incidence of complications (25%) such as meningitis or epilepsia crisis [2].

The intracranial approach (frontal craniotomy) shows the bony defect and the affected dura next to it. The extracranial approach, trans-ethmoidal, trans-septal or endoscopic endonasal, is indicated for the limited OMB of the anterior floor of the skull base with no associated cerebral lesion [2]. The endonasal endoscopic approach is the classical and most currently practiced because of the aesthetic benefit and conclusive results [7]. They allow the closing of OMB of the criblate plate or the roof of the ethmoid and sphenoid using grafts collected on site (nasal septum) or afar (abdominal fat, tragal cartilage, fascia lata) [2].

The first surgical step is to confirm the diagnosis. In the endoscopic endonasal approach, the surgeon “sees” the breach and the clear CSF flowing. Also, he can provoke the leakage by instrumentally repelling the meninges or the cerebral tissue herniated in the cavity or by Valsalva maneuver or jugular compression [2]. The contents of herniation are best explored through extracranial approach and should benefit from meticulous examination as long as they may modify the grafting technique [5]. The second surgical part consists of clogging the breach by an interposition technic with septal or turbinal mucosa graft, retroauricular or abdominal fat, fascia temporalis or fascia lata of the thigh or neuropatch [2]. As grafting material, the use of bone or cartilage is not required unless herniation of the meninges or brain is present [5] If unsuccessful, with persistent spontaneous fistulas, or large bone crash, or in the presence of a concomitant high-pressure hydrocephalus, a ventriculo-peritoneal or ventricular-atrial shunt is produced [7]. The two life-threatening postoperative complications are mainly represented by intracranial hypertension and meningitis which is prevented by IV injection of third generation of cephalosporin [7].

Conclusion

OMB of the anterior floor of the skull base should always be considered in front of a history of facial trauma or previous endonasal surgery. The main clinical sign is rhino-liquorrhea whose biological analysis confirms the CSF nature. The CT scan and MRI are the first line radiological investigations. And the treatment should take into consideration the type of the breach and the nature of the herniated content without suffering any delay regarding its life-threatening complications.

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A Rare Case of Frontal Lobe Abscess from Orbital Roof Blowout Fracture-Juniper publishers

Abstract

Orbital roof fractures are rare. These fractures are usually associated with high velocity impact and polytrauma, and if misdiagnosed, can have serious complications. This case demonstrates that orbital roof fractures can be easily missed from plain film radiographs and that clinical history and signs are of paramount importance in assessing these cases. This case also emphasizes the importance of multidisciplinary approach in trauma care.

Keywords: Frontal lobe abscess; Orbital roof fracture; Polytrauma

Introduction

Orbital roof fractures are usually associated with high impact trauma, accounting for approximately 1-9% of all maxillofacial fractures [1]. These fractures are mostly associated with other injuries in frontobasal trauma [2], although infants have a relatively high incidence of orbital roof fractures because of absent pneumatisation of the frontal sinus [3]. These fractures rarely present in isolation and can be associated with significant complications involving the eye, orbit, extraocular muscles, and brain.

Typically, the mechanism of injury for orbital roof fractures is high-velocity/impact trauma such as motor vehicle/bike accidents, and assaults. Facial lacerations as a result of the trauma may be present along with periorbital oedema, ecchymosis, ocular discomfort and epiphora. If there is involvement of the superior oblique or rectus muscles, the patient may have limitation of vertical or inward gaze or diplopia. Altered sensation in the distribution of the supraorbital and supratrochlear nerves may be present, and if the fracture is displaced, ex- or enophthalmos, hyper- or hypoglobus, or proptosis may result. Timely diagnosis of orbital roof fractures is imperative to prevent potential ophthalmological, neurological and cosmetic morbidity. This is confirmed with radiology, preferably computed tomography (CT).

Case Report

A medically fit 34-year-old woman initially presented to the Emergency department following a fall from her bike in which she hit the left orbit with handlebar. Plain film radiographs (OM 10o and 30o) showed no evidence of any facial fractures (Figure 1 & 2). Clinically, she had diplopia on lateral gaze associated with left eye and a small laceration on the upper eyelid which was glued by A & E. A 2-week review was planned by ophthalmology

She attended the eye casualty department 7 days after the initial trauma complaining of restriction of movement. Examination revealed restricted ocular motility and diplopia on all direction of gaze left eye particularly downwards.

A CT scan revealed a blowout fracture through the superomedial left orbital cavity with displaced fragments projected 2cm into the left frontal lobe and she was referred to Maxillofacial Surgery (Figure 3). Following discussion with neurosurgery an MRI was arranged to exclude brain abscess. This Figure 4 showed abscess formation around the left frontal lobe. The patient had urgent bi-frontal craniotomy and drainage of the abscess. Due to risk of infection of the bone or alloplastic graft, no roof repair was performed. She remains well at 6 months follow up with no signs of pulsatile exophthalmos or enophthalmos.

Discussion

Orbital roof fractures have been reported to account for between 1% and 9% of facial bone fractures [1,4]. Isolated orbital roof fractures are rare. The majority are associated with other forms of neurologic injury. They are often the result of high-energy impacts, such as motor vehicle accidents or falls [5]. Non-displaced or minimally displaced orbital roof fractures generally do not require surgical intervention and are managed conservatively [3]. However, displaced orbital roof fractures may be associated with significant neurologic, ophthalmologic, and aesthetic morbidities, such as blindness, globe rupture, eye immobility, altered sensation of the supraorbital and supratrochlear nerves, CSF leakage, intracranial injury, enophthalmos, exophthalmos, ectropion, entropion, infection, diplopia, restricted extraocular movements, blepharoptosis, orbital volume discrepancy, and those associated with the presence of foreign bodies [1]. Surgical approaches to the orbital roof present a risk of intracranial infection due to the proximity of the frontal sinuses, concomitant dura tears, and CSF leaks associated with pneumocephalus [6]. Surgical approaches require multidisciplinary strategies involving maxillofacial surgeons, neurosurgeons, and ophthalmologists. Early reconstruction, within 10 days of trauma, by stabilizing the midfacial fractures facilitates anatomical reconstruction because bone margins remain intact and helps to reduce the need for secondary operations and reduce the risk of infection [7].

Early recognition and treatment of orbital roof fractures can reduce the incidence of intracranial and ocular complications. CT scan plays a major role in the assessment of acute orbital trauma. This case demonstrates how plain film radiographs alone have a low sensitivity in diagnosing orbital roof fractures. Careful clinical assessment and early consideration for CT scans are important.

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Read the full paper at: http://www.scirp.org/journal/PaperInformation.aspx?PaperID=49932 DOI: 10.4236/ijohns.2014.35053 Author(s) Miguel Armengot-Carceller, Rosa Hernandez-Sandemetrio ABSTRACT Objectives: We critically reviewed our experiences in endocranial complications with Functional Endoscopic Sinus Surgery, and investigated the causes, prevention strategies and management. Methods: We conducted a retrospective study of endocranial complications with Functional Endoscopic Sinus Surgery performed during last 10 years in our ENT department. We analyzed endocranial complications, their causes, consequences, treatments and outcomes. Management was performed in collaboration with neurosurgeons and infectious diseases specialists. Results: Of 763 Functional Endoscopic Sinus Surgery procedures, we identified three cases with endocranial complications (0.393%).eww140925gjr These complications included: a case of postoperative severe cerebrospinal fluid leak in a patient treated for severe polyposis; a case of cerebral-frontal abscess with delayed clinical manifestation (4 weeks post-surgery) in a patient treated for chronic pansinusitis who experienced difficult surgery for septal spur; and a case of pneumocephalus in a patient treated for allergic fungal sinusitis. The clinical outcome was favorable in all cases. Conclusions: Intra-operative cerebrospinal fluid leak, anatomical deformities (even minimal deformities) and massive inflammatory sinus disease are predisposing factors for endocranial complications with Functional Endoscopic Sinus Surgery. Prognosis can be favorable when therapeutic management is carried out in collaboration with neurosurgeons and infectious disease specialists. KEYWORDS Cerebral Abscess, Cerebrospinal Fluid Leak, Inflammatory Sinus Disease, Pneumocephalus, Polyposis

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How Nursing Care Ease The Comfort For Neurological Patients

A principle goal for people with long-term neurological disabilities, whether conservative or progressive, is to live as long as possible an active life in the community. These patients' neurological management aims to reduce their impairment and consequent disability within society. Access to information, advice, and therapies from qualified health professionals, therapy, accommodation, provision of aids and equipment, personal assistance, transportation, and access to community are the most basic requirements to enable independent living with

Nursing Care For Neurosurgery Patient

.

Why Neurosurgery Patients Need Nursing Care?

Nursing Care by neurology-trained, intensive care physicians and staff have proven advantageous in minimizing in-hospital mortality and stay durability. Following surgery, neurological complications include focal deficits from cerebral neuropathy, intracranial hemorrhage, seizures, stroke, pneumocephalus and leaks of cerebrospinal fluid.

Postoperative Management for Neurosurgery includes:

Keep the head of the bed at thirty degrees to reduce intracranial pressure.

Maintain normal body temperatures.

Monitor swelling of the brain.

Complete frequent checks of overall skin integrity and surgical site status.

Monitor intake and output of fluids, drainage, and secretions.

Monitor respiratory status and encourage coughing and deep breathing; perform chest percussion to loosen secretions if warranted.

Control pain of the patient.

Do a passive range of motion exercises to keep the patient's joints and muscles strong.

In postoperative patients will require only 12-24 hours of ICU-level monitoring and can then be discharged to the general floor. The detect and intervene on the problem will directly affect the recovery and the level of function the patient achieves in recovery. Also to be considered is the pre-operative level of function and the underlying clinical condition for Patients.

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Spontaneous Pneumorrachis: A Complication of Nitrous Oxide Inhalation and Cocaine Snorting-Juniper publishers

Abstract

Context: Pneumorrhachis (PR) is an uncommon condition characterized by the presence of air within the spinal canal. Usually it results following trauma or surgery involving spinal instrumentation. Spontaneous pnemorrachis has also been described in association with spontaneous pneumomediastinum or secondary to marijuana smoking and cocaine snorting.

Findings: We report a case of spontaneous pnemorrachis in a patient who was snorting cocaine along with nitrous oxide inhalation for recreation.

Conclusion: It is helpful to elicit a history of illicit drug use, particularly regarding cocaine in a case of spontaneous pneumorrhachis.

Keywords: Pnemothorax; Drug abuse; Spine non trauma

Case Report

A 19 year male came to emergency department with shortness of breath and pleuritic chest pain. He had a history of inhalation of nitrous oxide and cocaine. He denied any trauma or recent air travel. On clinical examination he was anxious and tachypneic. There was extensive crepitus over the neck and anterior chest. CT scan of the chest showed extensive subcutaneous emphysema with pneumo-mediastinum and interstitial emphysema. Traces of pnemothoraces were seen in the apices and air was seen in spinal canal at C7/T1 level (Figure 1a & 1b). CT scan of the brain was reported to be normal. The neurological examination was entirely normal. He was managed conservatively with high flow oxygen inhalation. He improved clinically after 48 hours and was subsequently discharged for outpatients follow up.

Discussion

Spontaneous pnemorrachis is a rare entity, with one study reporting an incidence of 9.5% in a group of paediatric patient with newly diagnosed spontaneous pnemo-mediastinum [1]. Uses of Illicit stimulants such as cocaine, amphetamines, and their derivatives have been associated with development of pneumo-mediastinum [2]. Crack cocaine is most commonly associated with respiratory complications requiring hospital admission. Injections of methamphetamines have also been associated with pneumo-mediastinum and subcutaneous emphysema, along with pneumorrhachis [3]. Pneumorrhachis is classified as internal, intra-dural, external, and extradural [4]. Intradural PR is recognized by the presence of pneumocephalus without a head trauma wherein the air originates from a dural tear from a penetrating spinal injury. Traumatic external (intraspinal or extradural) PR usually recovers uneventfully; Traumatic internal PR is associated with major trauma and can be considered a severity marker [5].

Pneumorrhachis has been reported to result from the rupture of high-pressured alveoli (Macklin phenomenon) secondary to an acute increase in the transalveolar pressure gradient during a Valsalva manoeuvre. The air then may enter cervical subcutaneous tissues, mediastinum, pericardium, and epidural space, in the latter via the neural foramina and along the vascular and nerve root sheaths [6].

Of all the reported cases of spontaneous PR, four were reported to have developed neurologic signs and symptoms [710]. All the cases recovered without any specific intervention.

CT scan is the imaging modality of choice for diagnosis but differentiation between internal and external PR is difficult. Spontaneous PR is usually self limiting and there are no established guidelines for the management of spontaneous PR. It is usually treated conservatively as the air is reabsorbed by the blood stream with no consequence. A thorough evaluation of patients presenting with clinical signs and symptoms of pneumo-mediastinum should include a meticulous neurologic evaluation and CT imaging of the neck and chest to assess for concurrent PR.

Conclusion

Pneumorrachis is a self-limiting condition and resolves without any consequences. Prompt recognition of the underlying cause is essential for management planning. It is helpful to elicit a history of illicit drug use, particularly regarding amphetamines and cocaine.

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