Archives of Academic Emergency Medicine. 2021; 9(1): e22 https://doi.org/10.22037/aaem.v9i1.1172 CA S E RE P O RT Delayed post-traumatic Tension Hydropneumocephalus; a Case Report of Conservative Treatment Talayeh Mirkarimi1, Ehsan Modirian1, Peyman Namdar1, Mohammad Salek1∗ 1. Emergency Department; Rajaei Hospital, Medical Faculty, Qazvin University of Medical Science, Qazvin, Iran. Received: January 2021; Accepted: January 2021; Published online: 27 February 2021 Abstract: Pneumocephalus refers to the presence of air in the cranial cavity. Trauma is the most common cause of acquired pneumocephalus. Tension pneumocephalus occurs when intracranial accumulation of air causes high pressure on the brain as compared to extracranial pressure. Tension pneumocephalus is usually acute, and causes neu- rological symptoms, and its delayed form rarely occurs. A 12-year-old girl presented with a headache, lethargy, mild fever, and nausea from two days before admission to emergency department of Shahid Rajaei Hospital, Qazvin, Iran. The patient had a history of head trauma in a driving accident six weeks before and had under- gone brain computed tomography (CT) scan in another centre, which had revealed no sign of pneumocephalus. The patient had been treated for one week and had been discharged in good general condition. Considering her reduced consciousness, the patient underwent brain CT scan again in our centre. CT scan revealed tension hydropneumocephalus. The patient was transferred to the intensive care unit (ICU) for treatment. Considering the trend of her recovery, the patient was a candidate for conservative non-surgical therapy based on the in- charge neurosurgery specialist’s decision. The patient reported no complications during the six-month follow- up. Delayed tension pneumocephalus is among neurosurgery emergencies usually treated with early surgical intervention and dura defect restoration, but this patient received non-surgical treatment without any serious problem during the six-month follow-up. Keywords: Pneumocephalus; Craniocerebral Trauma; Conservative Treatment; Case Reports Cite this article as: Mirkarimi T, Modirian E, Namdar P, Salek M. Delayed post-traumatic Tension Hydropneumocephalus; a Case Report of Conservative Treatment . Arch Acad Emerg Med. 2021; 9(1): e22. 1. Introduction Pneumocephalus refers to a pathologic intracranial accumu- lation of air, and is categorized as epidural, subdural, sub- arachnoid, intra-parenchymal, and intra-ventricular types (1). Head and facial trauma is the most common cause of pneumocephalus and is responsible for 75% of cases (2). Other factors that can cause pneumocephalus include oti- tis media, skull base tumours, neurosurgical procedures (3), anaesthesia with nitric oxide, positive pressure ventilation, hyperbaric oxygen therapy, barotrauma, spinal anaesthesia, Intracranial Pressure (ICP) monitoring, intraoperative infu- sion of mannitol (4, 5), and gas-forming infections in the cen- tral nervous system (CNS). Moreover, spontaneous form has been rarely reported (3). Intracranial accumulation of gas can be acute (<72 hours) or delayed (>72 hours). Pneumo- ∗Corresponding Author: Mohammad Salek; Qazvin University of Medical Sci- ences, Bahonar Blvd, Qazvin, Iran. Email: mohammad_salek@yahoo.com, Phone Number: 00989380912244, ORCID: 0000-0002-4612-2746. cephalus is also divided into simple and tension types. Ten- sion pneumocephalus refers to the type that causes higher pressure on the brain parenchyma compared to extracra- nial pressure (6-8). Since this type can cause neurological disorders that are potentially life-threatening, such as cere- bral herniation, its early diagnosis is highly important (8). Here we present the case of a 12-year-old girl who presented with headache, lethargy, mild fever, and nausea from two days before admission to emergency department and his- tory of head trauma 6 weeks before. She was diagnosed with delayed tension hydropneumocephalus and treated by con- servative management without any problem during the 6- month follow-up. 2. Case presentation A 12-year-old girl presented to emergency department of Shahid Rajaei Hospital in Ghazvin, Iran, with headache, drowsiness, mild fever, nausea, vomiting, and lethargy form two day before admission. The patient had a history of head trauma in a driving accident six weeks before and had This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem T. Mirkarimi et al. 2 been hospitalized in Hamedan city, where she had under- gone spiral brain computed tomography (CT) scan without contrast due to reduced consciousness. Brain CT scan re- ported right frontal contusion, right frontal bone fracture in- volving frontal sinus and filling of ethmoid sinuses. The pa- tient had received treatment in that centre for one week and was discharged in good general condition. The patient did not report any history of seizures, otorrhoea, or rhinorrhoea during these six weeks. The presenting vital signs of the patient were as follows: pulse rate: 88/minute, respiratory rate: 18/minute, blood pressure: 105/75 mmHg, axillary Temperature: 37.8°C, Glasgow coma scale (GCS): 13/15 (eye response = 3, motor response = 6, ver- bal response = 4). Pupils were symmetrical of 3 millimetres and reduced response to light was detected in the right pupil. The four limbs had equal force of 5/5. Deep tendon reflexes (DTRs) were 2+ and symmetrical, and bilateral plantar reflex was symmetrical and downward. Other clinical examination findings were unremarkable. The patient underwent brain CT scan again in our cen- tre, which revealed hydropneumocephalus in the frontal parenchyma with midline shift and compression effect on the anterior horn of the lateral ventricles in the right frontal lobe (figure 1). Thus, the patient underwent treatment with phenytoin and 100% concentration oxygen. Moreover, given her mild fever and likelihood of brain abscess, a broad- spectrum antibiotic (Vancomycin) was administered until magnetic resonance imaging (MRI) was done. Neurosurgery emergency consultation was requested, and the patient was admitted to the Intensive care unit for further treatments. Considering the trend of recovery and at the neurosurgeon’s discretion, the patient was a candidate for conservative non- surgical therapy. MRI with contrast on the third day of admis- sion revealed no rim enhancement around the lesion, and confirmed the diagnosis of tension. hydropneumocephalus (figure 2). Therefore, antibiotic was discontinued. On the seventh day, the patient was advised to continue taking oral phenytoin, and was discharged in good general condition. The patient reported no complications during the six-month follow-up. 3. Discussion Two main theories usually explain the mechanism of devel- oping tension pneumocephalus: 1) the ball-valve theory, in which air enters the skull unilaterally, but cannot leave (9, 10). 2) Inverted soda valve bottle theory, in which, air is drawn into the skull by the negative pressure created due to reduced cerebrospinal fluid (CSF) volume (for whatever rea- son)(4, 5, 11). Headache is the most common symptom of pneumocephalus (12). The clinical presentation of tension pneumocephalus includes headache, generalized seizure, agitation, delirium, abnormal reflexes, changes in conscious- ness level, and changes in pupil size and response. Ten- sion pneumocephalus can mimic the manifestations of an intracranial space occupying lesion, and can lead to signs of brainstem displacement, including changes in respiratory rhythm and cardiac arrest, if it occurs in the posterior cranial fossa (13). Brain CT scan is the gold standard for diagnosis of tension pneumocephalus, which can also be diagnosed using plain radiography (3). The typical pathognomonic view of pneu- mocephalus is referred to as “Mount Fuji sign”, which is de- scribed as bilateral subdural hypoattenuation with compres- sion and detachment of the frontal lobes (14, 15). Generally, most cases with pneumocephalus need conservative treat- ment. Simple pneumocephalus with no neurological signs is treated by head elevation, administration of osmotic diuret- ics, analgesics and antipyretics, and also preventing manoeu- vres that increase intracranial pressure such as the Valsalva manoeuvre (2, 5). High concentration oxygen increases ab- sorption of pneumocephalus. Antibiotics are recommended if meningitis is suspected (3). In cases with tension pneu- mocephalus with substantial intracranial pressure, emergent decompression is indicated (2, 5, 16). Once air is aspirated, closure of dural defect is the only certain way to prevent re- currence of tension pneumocephalus (8). This case had several important points worth discussing. The patient’s brain CT scan showed tension pneumocephalus with air-fluid level, which is extremely rare (17). The patient had no external lacerations after the initial trauma and re- ported no history of posttraumatic rhinorrhoea or otorrhoea. In this patient, tension pneumocephalus can probably be ex- plained in the context of occult dural laceration fracture of the right frontal sinus and ethmoid sinus walls, which let air enter unilaterally (Ball-valve mechanism). Moreover, given the rare brain CT scan view and mild fever, an intracranial abscess (secondary to gas-forming organisms) is a highly im- portant differential diagnosis, which explains why a broad- spectrum antibiotic was administered for the patient until MRI was performed. 4. Conclusion Delayed tension pneumocephalus is a neurosurgical emer- gency and a complication rarely seen after head trauma, which requires prompt surgical intervention. However, de- pending on size and severity of signs and symptoms some cases could be managed conservatively and with long-term follow-up. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2021; 9(1): e22 Figure 1: Spiral brain CT scan without contrast (axial cut) revealed air-fluid level in the frontal parenchyma with midline shift and compres- sion effect on the anterior horn of the lateral ventricles in the right frontal lobe. Figure 2: Magnetic resonance imaging (MRI) with contrast (Axial, coronal and sagittal views) revealed no rim enhancement around the lesion, which ruled out brain abscess and confirmed tension hydropneumocephalus diagnosis. 5. Declarations 5.1. Acknowledgment We thank Dr. Mohammad Fathi, neurosurgeon, who partici- pated in case management. 5.2. Authors’ contributions TM was the lead author for this case report leading the initial patient management and writing the manuscript with sup- port from MS. EM and PN supervised the project. 5.3. Conflict of interest Talayeh mirkarimi, Mohammad Salek, Ehsan Modirian and Peyman Namdar declare that they have no conflict of interest 5.4. Funding and supports The Authors received no financial support for authorship or publication of this article. 5.5. Ethical consideration and patient’s consent Written informed consent was obtained from the patient’s parent for publication of this case report and accompanying images. References 1. Chhiber SS, Nizami FA, Kirmani AR, Wani MA, Bhat AR, Zargar J, et al. Delayed posttraumatic intraventricu- lar tension pneumocephalus: Case report. Neurosurgery Quarterly. 2011;21(2):128-32. 2. Leong K, Vijayananthan A, Sia S, Waran V. Pneumo- cephalus: an uncommon finding in trauma. The Medical journal of Malaysia. 2008;63(3):256-8. 3. Kankane VK, Jaiswal G, Gupta TK. Posttraumatic delayed tension pneumocephalus: Rare case with review of liter- ature. Asian journal of neurosurgery. 2016;11(4):343. 4. Solomiichuk VO, Lebed VO, Drizhdov KI. 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