Department of Otorhinolaryngology - Head and Neck Surgery

Case Study from our Complex Cases Series

Nithin A. Adappa, MD Assistant Professor of Otorhinolaryngology - Head and Neck Surgery

Mr. R, a 49 y/o male presented to the ER with a grand mal seizure and on imaging demonstrated significant pneumocephalus (Figure 1). Mr. R’s medical history included a history of motor vehicle accident at age 9 with multiple neurosurgical procedures including a shunt.

Imaging demonstrated air tracking intracranially from the left posterior ethmoid skull base with a meningoencephalocele in the ethmoid cavity (Figure 2), subsequently confirmed by MRI (not shown). Mr. R was taken to the OR for an endoscopic repair. At this time, he was noted on CT scan (Figure 3) to have an active CSF leak from the corresponding site. The leak was repaired with an underlay bone graft and an overlay vascularized nasoseptal flap. At two months, post-operative imaging demonstrates resolution of pneumocephalus and an intact bone graft with the overlying nasoseptal flap (Figure 4). 

Axial CT scan demonstrating massive pneumocephalus
Figure 1: Axial CT scan demonstrating massive pneumocephalus
Coronal CT scan demonstrating pneumocephalus with left ethmoid skull base defect with meningoencephalocele and small air bubbles in the area suggesting this was the etiology of the intracranial air.
Figure 2: Coronal CT scan demonstrating pneumocephalus with left ethmoid skull base defect with meningoencephalocele and small air bubbles in the area suggesting this was the etiology of the intracranial air.
Coronal CT scan 2 months post surgery demonstrating resolution of pneumocephalus as well as intact skull base (reconstructed with an underlay bone graft and overlay nasoseptal flap).
Figure 3: Triplanar view of defect and endoscopic vide demonstrating meningoencephalocele.
Triplanar view of defect and endoscopic vide demonstrating meningoencephalocele.
Figure 4: Coronal CT scan 2 months post surgery demonstrating resolution of pneumocephalus as well as intact skull base (reconstructed with an underlay bone graft and overlay nasoseptal flap).

Discussion

This case highlights an unusual presentation of a CSF leak as the patient was not displaying symptoms of CSF rhinorrhea. The source of the pneumocephalus was not initially apparent, but close evaluation of the CT scan demonstrated both a skull base defect at the posterior ethmoid roof with meningoencephalocele and smaller pockets of intracranial air tracking adjacent to the site. While Mr. R’s motor vehicle accident occurred 40 years previously, it is likely he had a defect from that time and long-standing increased intracranial pressures despite his shunt predisposed him to this condition. Given the increased pressures, it is important to place a rigid graft (in this case a bone graft) rather than a soft tissue reconstruction to help minimize recurrence. A vascularized pedicled flap also aids in rapid healing of the site.

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