QJM: An International Journal of Medicine, 2015, 835–836 doi: 10.1093/qjmed/hcv078 Advance Access Publication Date: 10 April 2015 Clinical picture
CLINICAL PICTURE
Mount Fuji sign following surgical drainage of spinal epidural abscess
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A 56-year-old male was admitted to the emergency department with complaints of fever, shortness of breath. The patient’s medical history included laryngectomy due to laryngeal cancer. He was found to have an anterior epidural abscess at C7–C8 and underwent surgical drainage. Four days later, he developed marked weakness of both legs. He deteriorated and neeeded intubation and ventilation due to progressive decrease in his level of consciousness. Computer tomography (CT) of the brain demonstrated an extensive pneumocephalus causing a mass effect, peaking of the frontal lobes and widening of the interhemispheric space (Figure 1). These findings were compatible with the Mount Fuji sign in tension pneumocephalus (TP). Cervical magnetic resonance (MR) imaging showed linear dural enhancement and dural defect at C7–C8. The patient was started on a higher concentration of oxygen. Under general anesthesia, a frontal burr-hole was made for aspiration of the air and insertion of a catheter drain. He became awake after hours and was extubated. After the procedure, he gained consciousness and his neurologic complaints regressed. Tension pneumocephalus is a life-threatening neurosurgical emergency and its early diagnosis is crucial. Intracranial air rarely may lead to extra-axial mass effect and cause altered level of consciousness, bradycardia and neurological deterioration. This entity is called tension penumocephalus. There are various etiological factors including; posterior fossa surgery, trauma, chronic subdural hematoma drainage and cerebrospinal drainage.1 Even 25 cm3 air is enough to produce TP in case of valve mechanism development. Patophysiologic process starts with leakage of cerebral spinal fluid in the presence of associated leptomeningeal tear. Development of negative intracranial pressure causes a vacuum effect which results in accumulation of air within the cranial cavity.2 The Mount Fuji sign is described by Japan neurosurgeons as bilateral subdural air collections which cause compression of
Figure 1. Mount Fuji sign, tension pneumocephalus. Axial noncontrast brain CT image demonstrates trapped air in subdural and interhemispheric space bilaterally causing interhemispheric widening, compression and peaking of the frontal lobes.
the frontal lobes and widening of the interhemispheric fissure. The collapsed frontal lobes have the appearance of the silhouette of Mount Fuji. The CT findings should correlate with clinical and neurological deterioration.3 Tension pneumocephalus is a neurosurgical emergency, unlike non-TP. Early diagnosis and surgical treatment are needed to prevent life-threatening deterioration.
Submitted: 25 March 2015; Revised (in revised form): 29 March 2015 C The Author 2015. Published by Oxford University Press on behalf of the Association of Physicians. V
All rights reserved. For Permissions, please email: [email protected]
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QJM: An International Journal of Medicine, 2015, Vol. 108, No. 10
The presence of the Mount Fuji sign on CT imaging helps distunguish between TP from nonpathologic subdural air (non-TP). Photographs and text from: I.E. Gokmen, S. Keskin and D. Kıresi, H. Erdog˘an, Department of Radiology, Selcuk University, 42 Dokuz St., Selcuklu-Konya 42075, Turkey; Necmettin Erbakan University, Meram School of Medicine, Beysehir St., MeramKonya, 42080, Turkey. email: [email protected]
References 1. Jason B, Patrick M. Tension pneumocephalus—The Mount Fuji sign. Can J Neurol Sci 2005; 32:538–9. 2. Nissar S, Irfan M, Yolande H, et al. Tension pneumocephalus as complication of burr-hole drainage of chronic subdural hematoma: A case report. Surg Neurol Int 2010; 1:27–32. 3. Amit MS, Deepak M. Mount Fuji sign in tension pneumocephalus. Ind J Neurotrauma 2009; 6:161–2.
Conflict of interest: None declared.
Downloaded from by guest on November 18, 2015
CLINICAL PICTURE
Mount Fuji sign following surgical drainage of spinal epidural abscess
Downloaded from by guest on November 18, 2015
A 56-year-old male was admitted to the emergency department with complaints of fever, shortness of breath. The patient’s medical history included laryngectomy due to laryngeal cancer. He was found to have an anterior epidural abscess at C7–C8 and underwent surgical drainage. Four days later, he developed marked weakness of both legs. He deteriorated and neeeded intubation and ventilation due to progressive decrease in his level of consciousness. Computer tomography (CT) of the brain demonstrated an extensive pneumocephalus causing a mass effect, peaking of the frontal lobes and widening of the interhemispheric space (Figure 1). These findings were compatible with the Mount Fuji sign in tension pneumocephalus (TP). Cervical magnetic resonance (MR) imaging showed linear dural enhancement and dural defect at C7–C8. The patient was started on a higher concentration of oxygen. Under general anesthesia, a frontal burr-hole was made for aspiration of the air and insertion of a catheter drain. He became awake after hours and was extubated. After the procedure, he gained consciousness and his neurologic complaints regressed. Tension pneumocephalus is a life-threatening neurosurgical emergency and its early diagnosis is crucial. Intracranial air rarely may lead to extra-axial mass effect and cause altered level of consciousness, bradycardia and neurological deterioration. This entity is called tension penumocephalus. There are various etiological factors including; posterior fossa surgery, trauma, chronic subdural hematoma drainage and cerebrospinal drainage.1 Even 25 cm3 air is enough to produce TP in case of valve mechanism development. Patophysiologic process starts with leakage of cerebral spinal fluid in the presence of associated leptomeningeal tear. Development of negative intracranial pressure causes a vacuum effect which results in accumulation of air within the cranial cavity.2 The Mount Fuji sign is described by Japan neurosurgeons as bilateral subdural air collections which cause compression of
Figure 1. Mount Fuji sign, tension pneumocephalus. Axial noncontrast brain CT image demonstrates trapped air in subdural and interhemispheric space bilaterally causing interhemispheric widening, compression and peaking of the frontal lobes.
the frontal lobes and widening of the interhemispheric fissure. The collapsed frontal lobes have the appearance of the silhouette of Mount Fuji. The CT findings should correlate with clinical and neurological deterioration.3 Tension pneumocephalus is a neurosurgical emergency, unlike non-TP. Early diagnosis and surgical treatment are needed to prevent life-threatening deterioration.
Submitted: 25 March 2015; Revised (in revised form): 29 March 2015 C The Author 2015. Published by Oxford University Press on behalf of the Association of Physicians. V
All rights reserved. For Permissions, please email: [email protected]
835
836
|
QJM: An International Journal of Medicine, 2015, Vol. 108, No. 10
The presence of the Mount Fuji sign on CT imaging helps distunguish between TP from nonpathologic subdural air (non-TP). Photographs and text from: I.E. Gokmen, S. Keskin and D. Kıresi, H. Erdog˘an, Department of Radiology, Selcuk University, 42 Dokuz St., Selcuklu-Konya 42075, Turkey; Necmettin Erbakan University, Meram School of Medicine, Beysehir St., MeramKonya, 42080, Turkey. email: [email protected]
References 1. Jason B, Patrick M. Tension pneumocephalus—The Mount Fuji sign. Can J Neurol Sci 2005; 32:538–9. 2. Nissar S, Irfan M, Yolande H, et al. Tension pneumocephalus as complication of burr-hole drainage of chronic subdural hematoma: A case report. Surg Neurol Int 2010; 1:27–32. 3. Amit MS, Deepak M. Mount Fuji sign in tension pneumocephalus. Ind J Neurotrauma 2009; 6:161–2.
Conflict of interest: None declared.
Downloaded from by guest on November 18, 2015
