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Pneumocephalus - StatPearls - NCBI Bookshelf
Pneumocephalus - StatPearls - NCBI Bookshelf
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Pneumocephalus
Joe M Das; Jitin Bajaj.
Author Information
Authors
Affiliations
1 Birmingham Children's Hospital, Steelhouse Ln, Birmingham B4 6NH
2 NSCB Govt. Medical College, Jabalpur
Objectives:
Introduction
Pneumocephalus (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.[1] Lecat first described this condition in 1741, but the term
"pneumocephalus" was coined independently by Luckett in 1913 and Wolff in 1914.[2][3]
[4] The term "tension pneumocephalus" (TP) was proposed in 1962 by Ectors, Kessler, and
Stern.[5]
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3. Pneumosinus dilatans is the same as pneumocele, but the walls of the sinus are intact and
normal.
Etiology
Congenital
Traumatic
Infectious
Neoplastic
Tumor eroding the skull or skull base like osteoma, epidermoid or pituitary adenoma
Iatrogenic
Transsphenoidal surgeries
Ventriculostomies
Spontaneous
Others
Barotrauma
Epidemiology
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The incidence of pneumocephalus depends on the etiology and is seen in almost all post-
craniotomy cases. The incidence following head injury varies depending on the series from 1%
to as high as 82%.[7][8]
Pathophysiology
During head injury or following cranial surgeries, dura may be opened or torn with or without
injury to arachnoid. In all these cases, air can get inside the cranial cavity. There are two
theories[5] about the mechanism for the development of pneumocephalus:
Ball valve theory of Dandy: Unidirectional movement of air from the outside environment
into the cranial cavity
The presence of air is a source of infection, which can lead to the development of meningitis.
Also, it can cause seizures by irritating the cerebral cortex.
4. Postoperative meningitis
Physical Examination
Evaluation
Skull X-ray
X-rays have been used in the past to identify the pneumocephalus, but it will miss small
quantities of air.
This is the gold standard investigation in the diagnosis of pneumocephalus. It can detect even
0.55 ml of intracranial air, whereas a skull radiograph requires at least 2 ml.[9] Air has a
Hounsfield coefficient of -1000. There are two signs which were identified as characteristic
of TP by Ishiwata et al.[10]
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1. "Mount Fuji sign" (named after Mount Fuji, the highest volcano mountain in Japan)
formed by the accumulation of air in the frontal region, with separation of tips of two
frontal lobes, in a patient in the supine position is diagnostic of tension pneumocephalus.
2. "Air bubble sign" denotes the presence of multiple air bubbles scattered in several cisterns
"Peaking sign" denotes bilateral compression of frontal lobes without separation of the tips. It
shows a less severe condition compared to the Mount Fuji sign.
MRI may also be useful, but not as sensitive as CT scan in the diagnosis of pneumocephalus.
Moreover, air may be mistaken for flow voids or blood products, and it appears dark in almost all
sequences.
Treatment / Management
Initial treatment of any head injury should follow the Advanced Trauma Life Support (ATLS)
protocol.
1. Bed rest
6. High flow oxygen therapy should be given (5 L per minute for five days at least) via a face
tent or 100% non-re-breather mask with absolute avoidance of positive pressure. The air is
composed of 78% nitrogen and 21% oxygen. The rate of nitrogen absorption from
pneumocephalus depends on the partial pressure of nitrogen in the blood, which is
inversely proportional to the FiO2. When clinicians supplement oxygen, the nitrogen
concentration in blood and brain tissue is reduced, increasing the nitrogen concentration
gradient for absorption between the air collection and surrounding brain tissue. Slowly
pneumocephalus will be replaced by oxygen, which has got high solubility within brain
tissue and blood, which, in turn, facilitates its absorption leading to the final resorption of
pneumocephalus.[11]
1. Symptomatic pneumocephalus
2. TP
3. Recurrent pneumocephalus
TP following cranial surgery can be treated by introducing a needle through the bur hole of the
previous craniotomy and aspirating the air with a syringe. Other cases of TP may require a fresh
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frontal bur hole and aspiration or insertion of a subdural drain connected to an underwater seal
followed by the closure of the dural defect, or insertion of saline primed Camino bolt.
Differential Diagnosis
Intracranial fat, although having a much higher density (-90 HU) compared to air (-1000 HU),
can appear hypodense on CT scans and can be mistaken for pneumocephalus.
Prognosis
Simple pneumocephalus is a condition that usually resolves by itself with conservative therapy.
Sometimes it can produce seizures and meningitis. Prognosis is usually good even with tension
pneumocephalus, provided timely treatment is given.
Complications
The following complications are likely to occur in a patient with pneumocephalus:
1. Meningitis
2. Seizures
3. Brain abscess
The following methods can be done to prevent the development of pneumocephalus after
neurosurgical procedures:
Filling of the surgical site with saline at the time of closure of the dura
Administering Valsalva maneuver before taking the last bite of a suture through the dura,
during its closure, to allow air to escape outside
A smaller gauge spinal needle makes a smaller dural perforation and prevents
cerebrospinal fluid leakage. Hence, such needles should be used while doing the lumbar
puncture.
Keeping the patient in the supine position with no head end of bed elevation following
chronic subdural hematoma evacuation
Positioning the head during dural closure in such a way that the last part of the dural defect
becomes the highest point to facilitate the escape of residual air while filling the subdural
space with saline
Nitrous oxide (N2O), an anesthetic agent, had been previously proposed to cause
pneumocephalus unless it is discontinued before the time of dural closure. But based on a
randomized control trial, such an adverse effect of N2O on intracranial pressure was not
noticed.[12]
Neurosurgical procedures can result in residual intracranial air and can also result in a continuous
entry of air into the cranial cavity. Hence the patient is advised to wait for at least seven days
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before taking a flight as the cabin pressure changes can introduce air inside the skull.[13]
References
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pneumocephalus after lumbar stab wound]. An Pediatr (Barc). 2019 Jan;90(1):63-64.
[PubMed: 29903638]
2. Yates H, Hamill M, Borel CO, Toung TJ. Incidence and perioperative management of tension
pneumocephalus following craniofacial resection. J Neurosurg Anesthesiol. 1994
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3. JELSMA F, MOORE DF. Cranial aerocele. Am J Surg. 1954 Mar;87(3):437-51. [PubMed:
13124659]
4. Schirmer CM, Heilman CB, Bhardwaj A. Pneumocephalus: case illustrations and review.
Neurocrit Care. 2010 Aug;13(1):152-8. [PubMed: 20405340]
5. Kankane VK, Jaiswal G, Gupta TK. Posttraumatic delayed tension pneumocephalus: Rare
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6. Pillai P, Sharma R, MacKenzie L, Reilly EF, Beery PR, Papadimos TJ, Stawicki SP.
Traumatic tension pneumocephalus - Two cases and comprehensive review of literature. Int J
Crit Illn Inj Sci. 2017 Jan-Mar;7(1):58-64. [PMC free article: PMC5364769] [PubMed:
28382259]
7. Jacobs JB, Persky MS. Traumatic pneumocephalus. Laryngoscope. 1980 Mar;90(3):515-21.
[PubMed: 7359973]
8. Steudel WI, Hacker H. Prognosis, incidence and management of acute traumatic intracranial
pneumocephalus. A retrospective analysis of 49 cases. Acta Neurochir (Wien). 1986;80(3-
4):93-9. [PubMed: 3716896]
9. Karavelioglu E, Eser O, Haktanir A. Pneumocephalus and pneumorrhachis after spinal
surgery: case report and review of the literature. Neurol Med Chir (Tokyo). 2014;54(5):405-
7. [PMC free article: PMC4533435] [PubMed: 24305016]
10. Ishiwata Y, Fujitsu K, Sekino T, Fujino H, Kubokura T, Tsubone K, Kuwabara T. Subdural
tension pneumocephalus following surgery for chronic subdural hematoma. J Neurosurg.
1988 Jan;68(1):58-61. [PubMed: 3335913]
11. Dexter F, Reasoner DK. Theoretical assessment of normobaric oxygen therapy to treat
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