Haemopneumoencephalus as a complication of transsphenoidal approach

Moreno-Carbonell, V.; Magno Serrano, J.; De Alonso Andrés, P.; Bueno Villalba, F.P.

doi:10.1016/j.redare.2021.09.013

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We present the image of an 84-year-old man weighing 72 kg who underwent endoscopic pituitary adenoma resection. The computed tomography (CT) image shows recent postoperative changes following resection of the sellar lesion using the transsphenoidal approach. Major dilatation of the ventricular system can be seen (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), with a significant amount of pneumoventricle inside, as well as haemoventricle in the occipital horns (yellow circle) and in the fourth ventricle, associated with transependymal oedema. Pneumocephalus bubbles in the frontal and left temporal region (yellow star). Associated with these findings, the patient also had a left parietal trephine hole and occupation of both nostrils and sphenoidal sinus by possible haemostatic material with mucosal thickening of ethmoid cells and maxillary sinuses bilaterally, which are not visualised in the section presented.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Intraventricular pneumocephalus is a rare complication of transsphenoidal approaches. The image shows an 84-year-old man, 72 kg ASA IV, independent for basic activities of daily living (BADL) with a frailty phenotype, who underwent endoscopic excision of a pituitary adenoma (pituitary macroadenoma) grade II Hardy classification. Comorbidities included chronic obstructive pulmonary disease (COPD), heart failure (HF) according to the New York Heart Association (NYHA) class II, hypertrophic cardiomyopathy, chronic left frontoparietal subdural haematoma due to a history of craniocerebral trauma 10 years previously and Parkinson's syndrome. Neurologically, the patient had a Glasgow score (GCS) of 15, normoreactive isochoric pupils, normal cranial nerves, without campimetric alterations, was able to move all four limbs, and with normal strength. He had intelligible dysarthria, without sensory disturbances or dysmetria. Cerebrospinal fluid was not drained during the operation due to intraoperative complications.Pneumocephalus (PC), or intracranial pneumatocele, or aerocele, is defined as the presence of air or gas in any endocranial (intraventricular, intraparenchymal, subarachnoid cisterns), subdural or even epidural compartment<a class="elsevierStyleCrossRef" href="#bib0005">1</a>. Lecat first described this condition in 1741, but the term “pneumocephalus” was coined independently by Luckett in 1913 and Wolff in 1914. The term “tension pneumocephalus” was proposed in 1962 by Ectors, Kessler, and Stern. However, it is classified as early PC (first seven days after surgery) vs. delayed PC (after seven days after surgery). It is also classified as acute PC (under 72 h) and delayed PC (72 h or later), although the clinical classification is more relevant: simple PC and tension PC (symptomatic).Simple cranioencephalic CT is the gold standard in the diagnosis of PC. CT can detect even .55 mL of intracranial air, whereas a skull X-ray requires at least 2 mL. Air has a Hounsfield coefficient of −1000 HU. Magnetic resonance imaging (MRI) can be useful, but is less sensitive than CT, and can sometimes confuse PC with blood products or flow voids.There are different signs on CT, depending on the location of the aerocele. The “air bubble sign” denotes the presence of multiple aeroceles scattered in different cisterns. Two signs have been identified<a class="elsevierStyleCrossRef" href="#bib0010">2</a> as characteristic of tension PC: Mount Fuji sign and peaking sign. On the other hand, ventricular air, also known as pneumoventricle or pneumatocele, has typical encephalic expression on CT, known as the angel wing sign of intraventricular pneumocephalus. The angel wing sign has been described earlier in paediatric chest radiography due to tension pneumomediastinum, but not in intracranial imaging<a class="elsevierStyleCrossRef" href="#bib0015">3</a>. McLaughlin's intracranial angel wing sign, a characteristic pattern of intraventricular pneumocephalus, is also seen in the authors' image. It is due to air passage after transsphenoidal surgery, with intraventricular dilatation and intrinsic pressure of the surrounding brain tissue, requiring medical and surgical treatment of symptomatic pneumocephalus. In addition, air is irritant and predisposes to infection. The transependymal oedema referred to in the case described suggests hypertensive hydrocephalus due to haemoventricle (blockage of cerebrospinal fluid outflow) and due to tension pneumoventricle even more so<a class="elsevierStyleCrossRef" href="#bib0015">3</a>." 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Campero" 1 => "P. Aljer" 2 => "E. Goldschmidt" 3 => "D. Bendersky" 4 => "A. Campero" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/2152-7806.104404" "Revista" => array:6 [ "tituloSerie" => "Surg Neurol Int." "fecha" => "2012" "volumen" => "3" "paginaInicial" => "S395" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23596554" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subdural tension pneumocephalus following surgery for chronic subdural hematoma" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Ishiwata" 1 => "K. Fujitsu" 2 => "T. Sekino" 3 => "H. Fujino" 4 => "T. Kubokura" 5 => "K. Tsubone" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/jns.1988.68.1.0058" "Revista" => array:6 [ "tituloSerie" => "J Neurosurg." "fecha" => "1988" "volumen" => "68" "paginaInicial" => "58" "paginaFinal" => "61" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3335913" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Angel Wing pneumocephalus Sign following transsphenoidal surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.C. McLaughlin" 1 => "K.L. Chaichana" 2 => "W.D. Freeman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Neuro-hospitalist." 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Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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Vol. 70. Issue 2.

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