Share
array:24 [ "pii" => "S2341192923000409" "issn" => "23411929" "doi" => "10.1016/j.redare.2021.10.007" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1411" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2021" "documento" => "article" "crossmark" => 0 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2023;70:160-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0034935621003078" "issn" => "00349356" "doi" => "10.1016/j.redar.2021.10.008" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1411" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Rev Esp Anestesiol Reanim. 2023;70:160-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Neumoencéfalo, coma y convulsiones después de una cirugía de descompresión lumbar" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "160" "paginaFinal" => "164" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Pneumocephalus, coma and seizures following lumbar decompression surgery" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 556 "Ancho" => 950 "Tamanyo" => 53440 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cortes axiales TC cerebral posquirúrgico: se visualiza neumoencéfalo subaracnoideo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Bonome Roel, M. Goday Etxebarria, C. Domenech Bendaña, A. Montero Picallo, B.I. Vieira Lopez" "autores" => array:5 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Bonome Roel" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Goday Etxebarria" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Domenech Bendaña" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Montero Picallo" ] 4 => array:2 [ "nombre" => "B.I." "apellidos" => "Vieira Lopez" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192923000409" "doi" => "10.1016/j.redare.2021.10.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000409?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621003078?idApp=UINPBA00004N" "url" => "/00349356/0000007000000003/v1_202302271739/S0034935621003078/v1_202302271739/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192923000392" "issn" => "23411929" "doi" => "10.1016/j.redare.2023.02.002" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1405" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 0 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2023;70:165-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Massive hemorrhage after arterioesophageal fistula from an unknown aberrant subclavian artery" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "165" "paginaFinal" => "168" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemorragia masiva tras fístula arterio-esofágica por una arteria subclavia aberrante desconocida" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 453 "Ancho" => 800 "Tamanyo" => 40023 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Angio-CT scan showing retroesophageal ARSA (arrow). Intra-oesophageal Sengstaken-Blakemore balloon.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Carballo Fernández, J. Arca Suárez, A. Prado Rodríguez, E. Freire Vila, D. Ruanova Seijo, M. Núñez Centeno" "autores" => array:6 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Carballo Fernández" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Arca Suárez" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Prado Rodríguez" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Freire Vila" ] 4 => array:2 [ "nombre" => "D." "apellidos" => "Ruanova Seijo" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Núñez Centeno" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935621003017" "doi" => "10.1016/j.redar.2021.10.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621003017?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000392?idApp=UINPBA00004N" "url" => "/23411929/0000007000000003/v1_202304111726/S2341192923000392/v1_202304111726/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2341192923000422" "issn" => "23411929" "doi" => "10.1016/j.redare.2021.11.009" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1416" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 0 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2023;70:156-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Gastric herniation due to rupture of diaphragmatic prosthesis in the postoperative period of pleuropneumonectomy due to mesothelioma: A complication to consider" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "156" "paginaFinal" => "159" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Herniación gástrica por rotura de prótesis diafragmática en el postoperatorio de pleuroneumonectomía por mesotelioma: una complicación a tener en cuenta" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 546 "Ancho" => 1250 "Tamanyo" => 91760 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A. Plain chest X-ray image showing a large chamber with hydro-aerial content in the left hemithorax and the nasogastric tube inside. B. Chest computed tomography image confirming the presence of the herniated gastric fundus in the thorax.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Cerra-Bergueiro, P. Rama-Maceiras, D. López-López, M. Gestal-Vázquez, M. Diaz-Allegue, M. Delgado-Roel" "autores" => array:6 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Cerra-Bergueiro" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Rama-Maceiras" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "López-López" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Gestal-Vázquez" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Diaz-Allegue" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Delgado-Roel" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000422?idApp=UINPBA00004N" "url" => "/23411929/0000007000000003/v1_202304111726/S2341192923000422/v1_202304111726/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Pneumocephalus, coma and seizures following lumbar decompression surgery" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "160" "paginaFinal" => "164" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "C. Bonome Roel, M. Goday Etxebarria, C. Domenech Bendaña, A. Montero Picallo, B.I. Vieira Lopez" "autores" => array:5 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Bonome Roel" "email" => array:1 [ 0 => "cbonome@outlook.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Goday Etxebarria" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Domenech Bendaña" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Montero Picallo" ] 4 => array:2 [ "nombre" => "B.I." "apellidos" => "Vieira Lopez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neumoencéfalo, coma y convulsiones después de una cirugía de descompresión lumbar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 556 "Ancho" => 950 "Tamanyo" => 53440 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Postoperative axial CT sections of brain: visualisation of subarachnoid pneumocephalus.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pneumocephalus is frequent after craniofacial trauma (74%) or in neurosurgery, however after spinal surgery it is rare.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Air has to penetrate the intradural space and diffuse into the brain. Opening of the dura mater is a complication of spinal surgery, and the initial mechanism for pneumocephalus.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Published cases of pneumocephalus in spinal surgery have been discovered through late presentation of impaired consciousness, headache, or even a seizure episode.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> The typical course is spontaneous recovery without sequelae treated conservatively.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We describe the clinical management and diagnostic procedures of a post-surgical spinal pneumocephalus in a patient who did not regain consciousness after anaesthesia and remained in coma for more than 12<span class="elsevierStyleHsp" style=""></span>h.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 54-year-old Caucasian female patient diagnosed with fibromyalgia and depressive syndrome, with no cognitive disturbance, who had undergone surgery for uterine cancer more than 10 years earlier. In recent years, lumbar pain radiating to the lower limbs with hypoaesthesia in the dorsum of the foot and heel pain when walking. She had undergone epidural infiltrations for L5-S1 radicular pain, with no improvement in pain. Chronic pharmacological treatment was bisoprolol, tapentadol, pregabalin, diazepam, duloxetine, naproxen, and agomelatine (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient had L4–L5 lumbar canal stenosis due to degenerative spondylolisthesis, and she underwent laminectomy and L4–L5 fixation with pedicle screws and 2 rods (Zodiac system.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The operation was performed under general anaesthesia with endotracheal intubation. Drugs used during induction were propofol (2<span class="elsevierStyleHsp" style=""></span>mg/kg), remifentanil (50<span class="elsevierStyleHsp" style=""></span>μg), and rocuronium (50<span class="elsevierStyleHsp" style=""></span>mg). Desflurane (6%) and remifentanil (.2<span class="elsevierStyleHsp" style=""></span>g/kg/min) were used for maintenance, and no additional doses of rocuronium were required.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient’s monitoring did not include an anaesthetic depth monitor or controlled mechanical ventilation (FiO<span class="elsevierStyleInf">2</span>: 50%; VT: 400; PEEP<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5).</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was positioned prone and in genupectoral decubitus. During surgery, the patient remained haemodynamically stable and without any incident of interest. At the end of the operation and after closing the wound, the neurosurgeon decided to revise the surgery as there was constant output from the vacuum drainage system; no vessel was found to be actively bleeding, so it was closed again, leaving the drainage tube without suction. The anaesthesiologist discontinued the desflurane, remifentanil, and reversed the neuromuscular blockade with sugammadex (200<span class="elsevierStyleHsp" style=""></span>mg). He attempted awakening the patient from anaesthesia for 1<span class="elsevierStyleHsp" style=""></span>h, and even gave flumazenil (.2<span class="elsevierStyleHsp" style=""></span>mg), despite the fact that no benzodiazepines had been administered, and informed that the patient was in coma.</p><p id="par0045" class="elsevierStylePara elsevierViewall">She was transferred to the resuscitation unit, intubated, and mechanically ventilated, and a few minutes later had a tonic-clonic seizure that was treated with diazepam (10<span class="elsevierStyleHsp" style=""></span>mg/iv). A cranial CT scan was performed and a diagnosis was made of subarachnoid pneumocephalus with air in the frontal and perisylvian sulci, in the cisterns of the base, interpeduncular and prepontine cisterns. A lumbar CT scan confirmed emphysema in the paravertebral musculature and in the extradural, extrathecal space with the transpedicular rod fixation device correctly inserted at L4–L5 and no injury to the dura mater detected.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The patient was maintained on mechanical ventilation (FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1) to denitrogenate the pneumocephalus, there was no response to verbal commands, only limb response to pain (Glasgow 7). Levetiracetam 1<span class="elsevierStyleHsp" style=""></span>g/iv/12<span class="elsevierStyleHsp" style=""></span>h was prescribed for the prophylaxis and treatment of the seizures.</p><p id="par0055" class="elsevierStylePara elsevierViewall">At 12<span class="elsevierStyleHsp" style=""></span>h, as the patient’s level of consciousness remained unchanged, a further cranial CT scan was performed, which showed practical resolution of the pneumocephalus, the compressive effect of the gas did not explain the patient’s low level of consciousness. An urgent electroencephalogram revealed that the patient was in status epilepticus, therefore phenytoin was added (bolus of 800<span class="elsevierStyleHsp" style=""></span>mg/iv and 400<span class="elsevierStyleHsp" style=""></span>mg/every 8<span class="elsevierStyleHsp" style=""></span>h). After 2<span class="elsevierStyleHsp" style=""></span>h the patient began to regain consciousness, spontaneous mobility, and started to obey commands. She was extubated 8<span class="elsevierStyleHsp" style=""></span>h later without any neurological sequelae (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The patient remained in the resuscitation unit for 48<span class="elsevierStyleHsp" style=""></span>h, without neurological alterations. At hospital discharge, the patient continued with oral levetiracetam, which was maintained for a few months.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Pneumocephalus is rare in spinal surgery, however it can cause multiple complications, which in our case included the impossibility of anaesthetic awakening, onset of tonic-clonic seizures, and even the induction of status epilepticus, probably related to the large volume of intracranial gas in the patient, which makes this case even more exceptional (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The described cases of pneumocephalus are generally diagnosed postoperatively due to headache, nausea, vomiting, meningismus, altered mental status, or seizures.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–10</span></a> The case we describe introduces a diagnosis of suspected pneumocephalus, due to inability to awaken the patient from anaesthesia, or coma, at the end of spinal surgery.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Confirmatory diagnosis is made with a cranial CT or MRI scan that shows air in the brain, although in the case of severely altered level of consciousness and generalized or focal seizures, an electroencephalogram should be performed to determine more precisely the brain's electrical activity and whether there is epileptiform activity. The current use of anaesthetic depth monitors, based on electroencephalography, can help us detect epileptiform activity during anaesthesia, but it was not used in this case.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Pneumocephalus is common in neurosurgery when opening the dura mater, where the continuous leakage of cerebrospinal fluid (CSF) generates a negative pressure in the subarachnoid space that absorbs air from the outside until the pressure between the subarachnoid space and the atmospheric pressure is equalised. Cases have also been reported where there has been no opening of the dura mater and pneumocephalus has occurred, for example, in the case of gas-producing bacteria.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In lumbar arthrodesis surgery, the presence of pneumocephalus was associated with the opening of the dura mater during surgery, in other cases it occurred without any anatomical abnormality in the dura mater being found in the MRI. In the latter, increased intra-abdominal pressure that could facilitate intradural air entry or removal of the calcified disc producing minimal rupture and acting as a valvular mechanism allowing the formation of the pneumocephalus were suggested as possible mechanisms. Air entry can be explained by the inverted bottle effect theory that as CSF exits, air enters the subarachnoid space.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Another possible mechanism is that the negative suction of the lumbar drain would contribute to the extraction of CSF and favour the entry of intradural air; this theory would be valid in cases where there are two drainage tubes one of which is disconnected, leaving it open and facilitating the entry of air due to the negative pressure of the other.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In our case, although no postoperative defect in the dura mater was found in the control CT scan, the pneumocephalus occurred during surgery and not in the postoperative period, and therefore the drain could not have been involved in its development. The most likely mechanism is that of the inverted bottle effect, and that air was entering during the operation given the large volume of the pneumocephalus due to inadvertent perforation of the dura mater. Our patient had only one drainage tube, at the end of the surgery when the vacuum system was placed it was draining haematic fluid that might have contained CSF as this drain was placed over the fascia.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Prevention of pneumocephalus during surgery should include measures to avoid injury to the dura mater and, if injury is detected, we should irrigate with saline to prevent the entry of air and also surgically close the dura mater. Positioning the patient in slight Trendelenburg also helps to prevent air from entering the intradural compartment.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,10</span></a> Avoiding the use of nitrous oxide during anaesthesia, because it diffuses into air spaces, is an additional measure to reduce the size of a possible pneumocephalus.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Pneumocephalus is usually treated conservatively if the symptoms are minimal; however, if the pneumocephalus is a tension pneumocephalus or there are indirect signs of intracranial hypertension, urgent evacuation may be required. Conservative treatment of pneumocephalus usually include avoiding elevating the head of the bed more than 30° so that the gas does not diffuse cranially, hydration, analgesia, antiemetic, anticonvulsant prophylaxis, and monitoring of the patient.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5,6</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In our case, the symptoms and magnitude of the pneumocephalus could have made us decide to evacuate it, but we decided on conservative management as there was no evidence of intracranial hypertension and we observed the clinical progression; however, at 12<span class="elsevierStyleHsp" style=""></span>h the patient no longer had a pneumocephalus and remained in coma (Glasgow<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7). Electroencephalography is essential to determine brain function and diagnose the probable cause of a decreased level of consciousness. Status epilepticus was diagnosed in our case, which required a synergistic combination of antiepileptic drugs for the patient to regain consciousness.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0110" class="elsevierStylePara elsevierViewall">Although pneumocephalus is a rare cause of coma after anaesthesia, it can occur in spinal surgery. Urgent imaging tests (CT or MRI) at cranial and spinal level and an electroencephalogram enable its diagnosis and guide us as to the most appropriate pharmacological or surgical treatment.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interests</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1882247" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1631453" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1882246" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1631454" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-03-23" "fechaAceptado" => "2021-10-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1631453" "palabras" => array:5 [ 0 => "Pneumocephalus" 1 => "Seizures" 2 => "Anesthesia" 3 => "Coma" 4 => "Spine surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1631454" "palabras" => array:5 [ 0 => "Pneumoencéfalo" 1 => "Convulsiones" 2 => "Anestesia" 3 => "Coma" 4 => "Cirugía espinal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We describe a patient with pneumocephalus following lumbar decompression surgery who presented altered mental status at time to awake of anaesthesia and the patient was admitted in intesive care unit in mechanical ventilation. The patient has not eye-opening response, no verbal response and motor response only withdraw in response to pain (7 points on Glasgow coma scale). Then, the patient experienced a generalized tonic-clonic seizure. Immediate cranial computed tomography (CT) images were performed. Cerebral pneumocephalus was present in CT, imaging revealed a voluminous pneumocephalus responsible for a significantspace-occupying effect on the frontal and parietal lobes, lateral ventricles and quadrigeminal plate cistern.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Anti-epileptic therapy (Diazepam and levetiracetam) and neurological monitoring were initiated. At 12 postoperative hours repeat CT scanning showed pneumocephalus were completely improved to minimal quantity and only limited to frontal lobe. The consciousness is impaired, and a generalized tonic-clonic seizure was present. Electroencephalogram showed continuous epileptiform activity and phenytoin IV was administered in continuous infusión. Four hours later the level of consciousness gradually improved, and the patient was right in eye opening, verbal and motor responses. A few hours later the patient was extubated, and no neurological deficits were present. Pneumocephalus should be considered in the differential diagnosis when evaluating a patient with altered mental status following lumbar surgery.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Describimos un caso de neumoencéfalo en una paciente con estenosis de canal medular por espondilolistesis degenerativa tras cirugía de descompresión lumbar. El caso comienza en el momento del despertar de la anestesia, en el que la paciente presenta bajo nivel de consciencia, sin respuesta de apertura ocular, ninguna respuesta verbal y la respuesta motora sólo retira en respuesta al dolor (Glasgow 7) que precisa ingreso en la unidad de cuidados intensivos para ventilación mecánica. Posteriormente la paciente experimentó una crisis convulsiva tónico-clónica generalizada por lo que se realizó una tomografía computarizada (TC) donde se observa un neumoencéfalo voluminoso con un efecto ocupante de espacio en los lóbulos frontal y parietal, los ventrículos laterales y la cisterna.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se inició terapia antiepiléptica (diazepam y levetiracetam) y vigilancia neurológica. A las 12 horas postoperatorias, la TC repetida demostró que el neumoencéfalo había mejorado persistiendo una cantidad mínima que sólo se limitaba al lóbulo frontal. La consciencia persistía severamente disminuida. El electroencefalograma mostró actividad epileptiforme continua y la adicción de fenitoína continua intravenosa (iv) al tratamiento antiepiléptico previo consigue mejorar gradualmente el nivel de consciencia y las respuestas motoras y verbales. A las pocas horas, la paciente fue extubada y no presentó déficits neurológicos posteriores. El neumoencéfalo debe considerarse en el diagnóstico diferencial cuando se evalúa a un paciente con un estado mental alterado después de una cirugía lumbar.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2541 "Ancho" => 1074 "Tamanyo" => 182406 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lateral X-ray, postoperative dorsolumbar spine reconstruction: L4–L5 fixation with pedicle screws.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 556 "Ancho" => 950 "Tamanyo" => 53440 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Postoperative axial CT sections of brain: visualisation of subarachnoid pneumocephalus.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 969 "Ancho" => 900 "Tamanyo" => 69490 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Axial CT section of brain: resolution of pneumocephalus.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumocephalus following facial injury [Article in Polish]" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "H. Kustrzycka" 1 => "J. Wrónski" 2 => "M. Bochnia" 3 => "A. Zarzycki" 4 => "M. Malczewski" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Otolaryngol Pol" "fecha" => "1995" "volumen" => "49" "paginaInicial" => "468" "paginaFinal" => "474" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9454211" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Symptomatic compressive pneumocephalus following lumbar decompression surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. Gauthe" 1 => "C. Latrobe" 2 => "C. Damade" 3 => "E. Foulongne" 4 => "X. Roussignol" 5 => "M. Ould-Slimane" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.otsr.2015.12.006" "Revista" => array:6 [ "tituloSerie" => "Orthop Traumatol Surg Res" "fecha" => "2016" "volumen" => "102" "paginaInicial" => "251" "paginaFinal" => "253" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26796946" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumocephalus following dorsal laminectomy: an unusual complication" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B. Kumar" 1 => "C. Banerjee" 2 => "S.N. Ghosh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/1793-5482.185059" "Revista" => array:6 [ "tituloSerie" => "Asian J Neurosurg" "fecha" => "2017" "volumen" => "12" "paginaInicial" => "772" "paginaFinal" => "773" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29114309" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumocephalus: an unusual case of postoperative seizure after intradural spine surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K.K. Lam" 1 => "A. Prasad" 2 => "M.G. Fehlings" 3 => "L. Venkatraghavan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s12630-014-0214-x" "Revista" => array:6 [ "tituloSerie" => "Can J Anaesth" "fecha" => "2014" "volumen" => "61" "paginaInicial" => "969" "paginaFinal" => "970" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25063536" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumocephalus: an unusual complication of lumbar arthrodesis. A clinical case and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Andarcia-Banuelos" 1 => "P. Cortés-García" 2 => "M.U. Herrera-Pérez" 3 => "B. Deniz-Rodríguez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.recot.2014.04.007" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Cir Ortop Traumatol" "fecha" => "2015" "volumen" => "59" "paginaInicial" => "222" "paginaFinal" => "226" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24906529" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Symptomatic pneumocephalus after lumbar disc surgery: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Z. Kizilay" 1 => "A. Yilmaz" 2 => "O. Ismailoglu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3889/oamjms.2015.028" "Revista" => array:6 [ "tituloSerie" => "Open Access Maced J Med Sci" "fecha" => "2015" "volumen" => "3" "paginaInicial" => "143" "paginaFinal" => "145" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27275212" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A rare complication of lumbar spinal surgery: pneumocephalus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "U. Ozdemir" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.13004/kjnt.2017.13.2.176" "Revista" => array:6 [ "tituloSerie" => "Korean J Neurotrauma" "fecha" => "2017" "volumen" => "13" "paginaInicial" => "176" "paginaFinal" => "179" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29201857" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Symptomatic pneumocephalus associated with lumbar dural tear and reverse trendelenburg positioning: a case report and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.M. Pirris" 1 => "E.W. Nottmeier" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1155/2013/792168" "Revista" => array:5 [ "tituloSerie" => "Case Rep Neurol Med" "fecha" => "2013" "volumen" => "2013" "paginaInicial" => "792168" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24455345" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumocephalus and seizures following epidural steroid injection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Sorber" 1 => "D. Levy" 2 => "A. Schwartz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ajem.2016.12.002" "Revista" => array:6 [ "tituloSerie" => "Am J Emerg Med" "fecha" => "2017" "volumen" => "35" "paginaInicial" => "1987.e1" "paginaFinal" => "1987.e2" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27955797" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diffuse pneumocephalus: a rare complication of spinal surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.H. Yun" 1 => "Y.J. Kim" 2 => "D.S. Yoo" 3 => "J.H. Ko" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3340/jkns.2010.48.3.288" "Revista" => array:6 [ "tituloSerie" => "J Korean Neurosurg Soc" "fecha" => "2010" "volumen" => "48" "paginaInicial" => "288" "paginaFinal" => "290" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21082062" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000007000000003/v1_202304111726/S2341192923000409/v1_202304111726/en/main.assets" "Apartado" => array:4 [ "identificador" => "65601" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000007000000003/v1_202304111726/S2341192923000409/v1_202304111726/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000409?idApp=UINPBA00004N" ]
