Stevens Baylee, Bialek Shannan, Zhao Kyle, Maqusi Suhair, Rassi Edward El, Tan Jeremy, Graffeo Christopher S
Departments of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States.
Departments of Plastic Surgery, University of Oklahoma, Oklahoma City, Oklahoma, United States.
J Neurol Surg Rep. 2024 Aug 30;85(3):e138-e143. doi: 10.1055/a-2376-7197. eCollection 2024 Jul.
Tension pneumocephalus is a rare postoperative complication, typically presenting with mental status changes or rapid neurological decline after craniotomy. We report a complex case of tension pneumocephalus triggered by graft retraction after ventriculoperitoneal (VP) shunt placement. A 39-year-old woman with a recurrent left trigeminal cavernous sinus schwannoma, status post one prior resection, two stereotactic radiosurgery treatments, and one course of fractionated radiotherapy, underwent radical resection with orbital exenteration and abdominal fat free graft reconstruction followed by adjuvant radiotherapy for malignant transformation. She developed subacute ventriculomegaly with altered mental status, prompting VP shunt placement. Three weeks later, she presented with profound pneumocephalus and intraventricular air originating from a large, left-sided sphenoid and maxillary defect, from which the fat graft had retracted. A right frontal external ventricular drain (EVD) was placed, resulting in immediate release of air under high pressure. Definitive treatment required skull base reconstruction with a latissimus dorsi free flap, contralateral nasoseptal flap, antibiotics, and VP shunt revision for treatment of combined cerebrospinal fluid (CSF) leak, pneumocephalus, ventriculitis, and low-pressure hydrocephalus. As of her last follow-up, she was restored to her initial postresection neurological baseline. Tension pneumocephalus is a rare and life-threatening emergency that requires immediate neurosurgical intervention. We report the index case of tension pneumocephalus induced by graft retraction following radiotherapy and CSF diversion. Where observed, tension pneumocephalus resulting from a skull base CSF leak may be associated with low-pressure hydrocephalus, and successful long-term management demands balancing the need for CSF diversion against the integrity of the skull base reconstruction.
张力性气颅是一种罕见的术后并发症，通常在开颅术后出现精神状态改变或迅速的神经功能衰退。我们报告一例因脑室腹腔（VP）分流术后移植物回缩引发的复杂张力性气颅病例。
一名39岁女性，患有复发性左侧三叉神经海绵窦神经鞘瘤，曾接受过一次手术切除、两次立体定向放射外科治疗以及一个疗程的分次放射治疗，此次接受了根治性切除并眶内容剜出术，随后进行腹部游离脂肪移植重建，术后接受辅助性放疗以治疗恶性转化。她出现了伴有精神状态改变的亚急性脑室扩大，遂行VP分流术。三周后，她出现严重气颅及脑室内积气，气体系源于左侧巨大的蝶骨和上颌骨缺损处，脂肪移植物已从此处回缩。放置了右侧额部脑室外引流管（EVD），随即引出了高压下的气体。确定性治疗需要采用背阔肌游离皮瓣、对侧鼻中隔皮瓣进行颅底重建，使用抗生素，并对VP分流进行修正，以治疗合并存在的脑脊液（CSF）漏、气颅、脑室炎和低压性脑积水。截至她最后一次随访时，已恢复到切除术后最初的神经功能基线状态。
张力性气颅是一种罕见且危及生命的急症，需要立即进行神经外科干预。我们报告了这例放疗及CSF分流术后因移植物回缩导致张力性气颅的病例。在观察到的病例中，由颅底CSF漏引起的张力性气颅可能与低压性脑积水相关，而成功的长期管理需要在CSF分流需求与颅底重建完整性之间取得平衡。
