Case 11: pneumocephalus

posted: November 17, 1996

Resident: Greg Dowd, MD
Attending: Rand Voorhies, MD

CLINICAL PRESENTATION: This 72 year old woman presented to the ER with an one week history of progressive left sided weakness as well as slurring of speech. In addition, the patient had the sensation of "air blowing in her left ear". Examination revealed an elderly female who was mildly confused with a generalized left sided hemiparesis (including the face) and expressive dysphasia. No other neurological deficits were noted. In addition, the tympanic membranes were normal.

DIAGNOSTIC STUDIES: A cranial CT scan was obtained:

This noncontrast scan reveals pneumocephalus.

The patient indeed had "air in her head" as she stated on admission.

What would you do at this point? What is the etiology of this spontaneous pneumocephalus?

Please comment: dawast@lsuhsc.edu

STEPS TAKEN AT LSU: Initially a ventriculostomy was placed with transient improvement of symptoms and persistence of pneumocephalus. A repeat CT scan was performed with bone windows- see below for a select bone window view:

Note the defect in the petrous bone (red marker)- the source of the air leak. You can actually see the air percolating out from the mastoid air cells! At this point a subtemporal craniotomy (left) was performed with extradural exploration. A small hole ws found in the petrous bone area with adherent dura (no obvious hole in the dura). Repair was performed with cadaveric dura and fibrin glue.

POSTOPERATIVE COURSE: Patient remained asymptomatic and the follow-up CT scan showed resolution of the pneumocephalus.

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