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Symptomatic Pneumocephalus After Trans-sphenoidal Surgery Jessie Teng, Richard J. MacIsaac, and Yi Yuen Wang Department of Endocrinology & Diabetes (J.T., R.J.M.), and Department of Neurosurgery (Y.Y.W.), St Vincent’s Hospital, Fitzroy, VIC 3065, Australia; and University of Melbourne (R.J.M.), Parkville, VIC 3010, Australia
43-year-old woman underwent endoscopic transsphenoidal resection of a 34-mm nonfunctioning pituitary macroadenoma with optic chiasmal compression. Cerebrospinal fluid (CSF) leak was noted and repaired with gelfoam and a duraseal (hydrogel sealant) buttressed with Nasopore. Day 4 postsurgery, she had ongoing postnasal drip, and she rapidly deteriorated with headaches, drowsiness, vomiting, and urinary incontinence. She was receiving adequate hydrocortisone replacement, serum sodium levels were normal, and CSF cultures excluded infection. Brain computed tomography (CT) showed significant pneumocephalus with mass effect (Figure 1). Figure 2 shows air in the prefrontal region (Mount Fuji sign) and cisterns (air bubble sign) on coronal sections. Initial management comprised high-flow oxygen therapy and a lumbar drain with controlled CSF release. Despite treatment, she developed Cushing’s reflex, with systemic hypertension and bradycardia, suggesting intracranial hypertension. Serial imaging demonstrated progressive tension pneumocephalus, and the lumbar drain was clamped. Repeat surgery confirmed a moderate CSF leak (Daniel Kelly system grade 2) (1), which was repaired using a fat graft. Neurological status markedly improved, and there was complete clinical recovery. Symptomatic tension pneumocephalus after transsphenoidal pituitary surgery is a rare but serious complication, necessitating rapid recognition (2, 3). Conservative treatment with high-flow oxygen increases the rate of resorption of pneumocephalus (4). Early surgical repair of
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ISSN Print 0021-972X ISSN Online 1945-7197 Printed in U.S.A. Copyright © 2014 by the Endocrine Society Received October 22, 2013. Accepted March 25, 2014. First Published Online April 7, 2014
doi: 10.1210/jc.2013-3865
the CSF leak should be considered in moderate to severe cases (5). Lumbar drainage in the presence of intraoperative CSF leak and significant pneumocephalus may exacerbate the pneumocephalus by drawing in air from the nasal passages.
Acknowledgments Address all correspondence and requests for reprints to: Dr Jessie Teng, Department of Endocrinology and Diabetes, St Vincent’s Hospital, P.O. Box 2900, Fitzroy VIC 3065, Australia. E-mail: [email protected]. Disclosure Summary: The authors have nothing to disclose.
References 1. Wang YY, Kearney T, Gnanalingham KK. Low-grade CSF leaks in endoscopic trans-sphenoidal pituitary surgery: efficacy of a simple and fully synthetic repair with a hydrogel sealant. Acta Neurochi (Wein). 2011;153:815– 822. 2. Sawka AM, Aniszewski JP, Young WF Jr, Nippoldt TB, Yanez P, Ebersold MJ. Tension pneumocranium, a rare complication of transsphenoidal pituitary surgery: Mayo Clinic experience 1976 –1998. J Clin Endocrinol Metab. 1999;84:4731– 4734. 3. Davis DH, Laws ER Jr, McDonald TJ, Salassa JR, Phillips LH 2nd. Intraventricular tension pneumocephalus as a complication of paranasal sinus surgery: case report. Neurosurgery. 1981; 8:574 –576. 4. Gore PA, Maan H, Chang S, Pitt AM, Spetzler RF, Nakaji P. Normobaric oxygen therapy strategies in the treatment of postcraniotomy pneumocephalus. J Neurosurg. 2008;108:926 –929. 5. Haran RP, Chandy MJ. Symptomatic pneumocephalus after transsphenoidal surgery. Surg Neurol. 1997;48:575–578. Abbreviations: CSF, cerebrospinal fluid; CT, computed tomography.
J Clin Endocrinol Metab, July 2014, 99(7):2319 –2320
jcem.endojournals.org
The Endocrine Society. Downloaded from press.endocrine.org by [${individualUser.displayName}] on 18 February 2015. at 05:56 For personal use only. No other uses without permission. . All rights reserved.
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Pneumocephalus Post-TSS
J Clin Endocrinol Metab, July 2014, 99(7):2319 –2320
Figure 1. Sagittal section of brain CT showing significant pneumocephalus with mass effect (arrow).
Figure 2. Axial section of brain CT showing air in the prefrontal region (Mount Fuji sign, arrow) and cisterns (air bubble sign, asterisk).
The Endocrine Society. Downloaded from press.endocrine.org by [${individualUser.displayName}] on 18 February 2015. at 05:56 For personal use only. No other uses without permission. . All rights reserved.
i n
F E A T U R E
E n d o c r i n o l o g y
Symptomatic Pneumocephalus After Trans-sphenoidal Surgery Jessie Teng, Richard J. MacIsaac, and Yi Yuen Wang Department of Endocrinology & Diabetes (J.T., R.J.M.), and Department of Neurosurgery (Y.Y.W.), St Vincent’s Hospital, Fitzroy, VIC 3065, Australia; and University of Melbourne (R.J.M.), Parkville, VIC 3010, Australia
43-year-old woman underwent endoscopic transsphenoidal resection of a 34-mm nonfunctioning pituitary macroadenoma with optic chiasmal compression. Cerebrospinal fluid (CSF) leak was noted and repaired with gelfoam and a duraseal (hydrogel sealant) buttressed with Nasopore. Day 4 postsurgery, she had ongoing postnasal drip, and she rapidly deteriorated with headaches, drowsiness, vomiting, and urinary incontinence. She was receiving adequate hydrocortisone replacement, serum sodium levels were normal, and CSF cultures excluded infection. Brain computed tomography (CT) showed significant pneumocephalus with mass effect (Figure 1). Figure 2 shows air in the prefrontal region (Mount Fuji sign) and cisterns (air bubble sign) on coronal sections. Initial management comprised high-flow oxygen therapy and a lumbar drain with controlled CSF release. Despite treatment, she developed Cushing’s reflex, with systemic hypertension and bradycardia, suggesting intracranial hypertension. Serial imaging demonstrated progressive tension pneumocephalus, and the lumbar drain was clamped. Repeat surgery confirmed a moderate CSF leak (Daniel Kelly system grade 2) (1), which was repaired using a fat graft. Neurological status markedly improved, and there was complete clinical recovery. Symptomatic tension pneumocephalus after transsphenoidal pituitary surgery is a rare but serious complication, necessitating rapid recognition (2, 3). Conservative treatment with high-flow oxygen increases the rate of resorption of pneumocephalus (4). Early surgical repair of
A
ISSN Print 0021-972X ISSN Online 1945-7197 Printed in U.S.A. Copyright © 2014 by the Endocrine Society Received October 22, 2013. Accepted March 25, 2014. First Published Online April 7, 2014
doi: 10.1210/jc.2013-3865
the CSF leak should be considered in moderate to severe cases (5). Lumbar drainage in the presence of intraoperative CSF leak and significant pneumocephalus may exacerbate the pneumocephalus by drawing in air from the nasal passages.
Acknowledgments Address all correspondence and requests for reprints to: Dr Jessie Teng, Department of Endocrinology and Diabetes, St Vincent’s Hospital, P.O. Box 2900, Fitzroy VIC 3065, Australia. E-mail: [email protected]. Disclosure Summary: The authors have nothing to disclose.
References 1. Wang YY, Kearney T, Gnanalingham KK. Low-grade CSF leaks in endoscopic trans-sphenoidal pituitary surgery: efficacy of a simple and fully synthetic repair with a hydrogel sealant. Acta Neurochi (Wein). 2011;153:815– 822. 2. Sawka AM, Aniszewski JP, Young WF Jr, Nippoldt TB, Yanez P, Ebersold MJ. Tension pneumocranium, a rare complication of transsphenoidal pituitary surgery: Mayo Clinic experience 1976 –1998. J Clin Endocrinol Metab. 1999;84:4731– 4734. 3. Davis DH, Laws ER Jr, McDonald TJ, Salassa JR, Phillips LH 2nd. Intraventricular tension pneumocephalus as a complication of paranasal sinus surgery: case report. Neurosurgery. 1981; 8:574 –576. 4. Gore PA, Maan H, Chang S, Pitt AM, Spetzler RF, Nakaji P. Normobaric oxygen therapy strategies in the treatment of postcraniotomy pneumocephalus. J Neurosurg. 2008;108:926 –929. 5. Haran RP, Chandy MJ. Symptomatic pneumocephalus after transsphenoidal surgery. Surg Neurol. 1997;48:575–578. Abbreviations: CSF, cerebrospinal fluid; CT, computed tomography.
J Clin Endocrinol Metab, July 2014, 99(7):2319 –2320
jcem.endojournals.org
The Endocrine Society. Downloaded from press.endocrine.org by [${individualUser.displayName}] on 18 February 2015. at 05:56 For personal use only. No other uses without permission. . All rights reserved.
2319
2320
Teng et al
Pneumocephalus Post-TSS
J Clin Endocrinol Metab, July 2014, 99(7):2319 –2320
Figure 1. Sagittal section of brain CT showing significant pneumocephalus with mass effect (arrow).
Figure 2. Axial section of brain CT showing air in the prefrontal region (Mount Fuji sign, arrow) and cisterns (air bubble sign, asterisk).
The Endocrine Society. Downloaded from press.endocrine.org by [${individualUser.displayName}] on 18 February 2015. at 05:56 For personal use only. No other uses without permission. . All rights reserved.
