Traumatic Intracranial Aerocele With Progressive Blindness – A case report

Abstract

Background:

Traumatic intracranial aerocele, also known as pneumocephalus, is an uncommon condition that may be asymptomatic or may present with progressive neurological deficits and life threatening conditions that demand urgent decompressive craniotomy to reduce the acute rise in intracranial pressure and the sequelae.

Aims & Objectives

A high degree of suspicion and continuous neurological monitoring are essential for the early detection and the prompt neurosurgical intervention demanded for the achievement of a good outcome in patients following traumatic acute severe head injury with life threatening neurological complications.

Method

Presentation of a young motorcyclist who was not wearing a crash helmet and was involved in a road traffic accident in which he sustained a compound cranio-facial injury with loss of consciousness and symptomatic intracranial aerocele.

Results

The case of a 28-year old motorcyclist without a helmet, following a road traffic accident, sustained compound skull fracture with CSF rhinorrhea, ventricular aerocele and progressive blindness who recovered his vision fully following bitemporal decompressive craniotomy.

Conclusion

A high index of suspicion enabled early detection and prompt decompressive craniotomy that stemmed the progressive loss of vision in this patient with an uncommon but symptomatic intracranial aerocele and cranio-facial compound head injury.

Introduction

Skull base fractures that involve the paranasal sinuses and cause a tear in the dura may produce traumatic intracranial aerocele and a channel through which air may be sucked into the extradural, subarachnoid and subdural spaces as well as the ventricles and the brain parenchyma. Intracranial aeroceles occur in 0.5 to 1% of head trauma cases1,2. Diagnosis is clinical with focal neurologic features3, leakage of cerebrospinal fluid and the presence of aeroceles confirmed on plain skull x-ray or CT scan4,5. The current treatment of intracranial aerocele and CSF rhinorrhea is conservative in the early stages and graduate to surgery when neurologic symptoms appear; surgery is aimed at letting out the air and to close the meningeal tear6,7,8. We report a case of persistent traumatic intracranial aerocele with CSF rhinorrhea and progressive blindness in a 28-year old man following severe acute traumatic cranio-facial injury from a road traffic accident. He fully recovered his vision following a decompressive bitemporal craniotomy.

Case Reports

A 28-year old male motorcycle rider who was not wearing a crash helmet was involved at high speed in a head-on collision with a car and was thrown off. He landed with the left side of his head at impact, lost consciousness and bled from both nostrils and mouth. He was initially taken to a cottage hospital where he regained consciousness three days later. He complained of a throbbing headache and diminishing vision in both eyes. He experienced drainage of clear fluid from the left nostril. He was managed conservatively with third generation cephalosporin, tetanus prophylaxis, analgesics and elevation of his head. He was thereafter referred to the Accident and Emergency Unit of Jos University Teaching Hospital (JUTH), Jos, Nigeria on the tenth post trauma day because his symptoms had worsened. He was fully conscious with a Glasgow Coma Scale (GCS) of 15 on arrival in JUTH; the pupils were 3mm in diameter bilaterally and he had bilateral peri-orbital oedema. His vision was reduced to light perception, could not see objects placed 15 cm from his eyes and he had bilateral papilloedema. He was led around by his relatives. There was no neck rigidity or fever. The pulse rate was 70 beats/minute with blood pressure of 120/80mmHg. Clear fluid continuously drained from the left nostril, which produced a double halo sign on blotting paper. His cerebrospinal fluid (CSF) culture was sterile and his haemogram, urea, electrolytes and creatinine were all within normal limits. Plain radiograph of his skull showed free air in both lateral ventricles (Figures I & 2). He was given intravenous intravenous crystalline penicillin and chloramphenicol as well as mannitol. He was promptly taken to the operating room where under general anaesthesia he had a decompressive bitemporal craniotomy. A tube drain was left in place connected to underwater seal drainage system. He made remarkable improvement by the second post-operative day as the CSF leakage stopped, the vision improved starting with clear vision for near objects and three days later, to full vision. His post-operative skull x-rays (Figures 3 & 4) showed complete resolution of his intra-cerebral aerocele. Fundoscopy also showed resolution of the papilloedema. He was discharged on the fifth postoperative day and has been followed up for six months without symptoms.

Conclusions

Symptomatic traumatic intracranial aeroceles are features of uncommon but severe craniofacial injuries which resolve with prompt and adequate surgery. Early recognition of this entity requires high index of suspicion.

Discussion

Traumatic intracranial aerocele is an uncommon condition indicating a compound fracture through the paranasal sinuses associated with dural and cerebral tear. Fracture of the base of skull with tear of the dura is a reflection of the force of impact and the severity of head injury as is often seen in motorcyclists driving without helmet. The neurological complications of traumatic intracranial aerocele include epilepsy, dementia7 and progressive blindness. Helmet use has been shown to prevent severe craniofacial injuries and reduce the risk of death in motorcyclists involved in traffic accidents12.

Intracranial aerocele could also be caused by a frontal sinus osteoma growing into the cranial fossa8 and could complicate surgery for osteoma of the paranasal sinuses13,14. In these two situations, surgery is the management option with good outcome. However, in traumatic intracranial aerocele, the treatment is initially conservative with appropriate antibiotics, tetanus prophylaxis, elevation of the head and prevention of nose blowing15. Surgery is the treatment of choice once neurological symptoms appear or cerebrospinal fluid leakage persists,16. The result of surgery is good with resolution of neurologic symptoms if surgery is prompt and adequate16.