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Table of Contents    
Year : 2020  |  Volume : 68  |  Issue : 6  |  Page : 1488-1489

Persisting Postoperative Pneumocephalus after Cranioplasty in Sunken Skin Flap Syndrome

Department of Neurosurgery, Zhongshan City People's Hospital, Zhongshan, Guangdong, China (528403), China

Date of Web Publication19-Dec-2020

Correspondence Address:
Dr. Wen-jian Zheng
Department of Neurosurgery, Zhongshan City People's hospital, Sunwen East Road the 2nd, Zhongshan, Guangdong
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.304089

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How to cite this article:
Zheng Wj, Li Lm, Lin Sh. Persisting Postoperative Pneumocephalus after Cranioplasty in Sunken Skin Flap Syndrome. Neurol India 2020;68:1488-9

How to cite this URL:
Zheng Wj, Li Lm, Lin Sh. Persisting Postoperative Pneumocephalus after Cranioplasty in Sunken Skin Flap Syndrome. Neurol India [serial online] 2020 [cited 2021 Jan 22];68:1488-9. Available from:


A 26-year-old male patient suffering a head injury in a car accident was admitted in our hospital. Bifrontal decompressive craniectomy (DC) was performed because of intracranial hypertension and frontal bone comminuted fracture. The patients survived with a Glasgow Coma Scale of 11 (E4V2M5) and a Glasgow Outcome Scale of 2. An evident sunken skin flap was observed and a titanium cranioplasty (CP) was performed after a 4-month hospital stay. Preoperative cranial defect [Figure 1]a and head CT [Figure 1]b were displayed, respectively. Palpable subcutaneous hygroma was evident in the first two weeks. The head CT showed mix extradural effusion and hematoma [Figure 1]c, [Figure 1]d. Hence, the percutaneous puncture was performed daily for drainage until subcutaneous hygroma subsided. The extradural air gradually replaced the fluid [Figure 1]e. Cefodizime was administrated in the first month because of pulmonary infection. The patient was kept in a supine position besides in the first hour after feeding. The pneumocephalus disappeared in three months [Figure 1]f.
Figure 1: The changes of postoperative extradural collection after CP in a patient with SSFS (a) patient with huge bifrontal cranial defect (b) preoperative head CT (c) postoperative head CT on the 1st da (d) postoperative head CT on the 3rd day (e) postoperative head CT on the 1st month (f) postoperative head CT on the 3rd month

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Sunken skin flap syndrome (SSFS) is a rare complication characterized by the concave cranial defect and neurological deficits usually beginning weeks to months after DC.[1] Postoperative extradural collection in CP can occur in patients with SSFS. The collection is usually a mixture of effusion, hematoma, and air. Tensive pneumocephalus following CP had been reported in several patients with pre-exist ventriculoperitoneal shunt.[2],[3],[4],[5],[6],[7] It is an emergency and requires puncture and suction. Non-tensive pneumocephalus in CP is relatively benign. It can be found in patients with a huge defect and moist air can be absorbed in 3-5 days. However, persisting pneumocephalus attributed to a frontal sinus opening is extremely rare. It can persist for a long period until the fistula closed. Surgical debridement to occlude the fistula is effective,[8] but it bears the risk of graft infection.

For this patient, a communicating frontal sinus was obviously seen. Sinus secretion can gradually occlude the fistula and act as a “one-way valve”. Air will be released through the valve upon each cerebral pulsation. Subsequent ventricles re-expansion occurs after the lowering of intracranial pressure. Keeping the frontal sinus opening in the apex with a supine position furtherly facilitates air elimination.

The decision of treatment strategy is determined by the integrity of dura mater. Surgery should not be hesitated for patients with evident rhinorrhea as it highly increases the risk of intracranial infection. Although there is no evidence supporting that pneumocephalus increases CP infection, application of antibiotics may help reduce infection resulting from regurgitation and aspiration.

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There are no conflicts of interest.

  References Top

Ashayeri K, M Jackson E, Huang J, Brem H, Gordon CR. Syndrome of the trephined: A systematic review. Neurosurgery 2016;79:525-34.  Back to cited text no. 1
Killeen T, Fortunati M, Myanger E, Rüfenacht D, Ryskeldiyev N, Akshulakov S, et al. Symptomatic tension pneumocephalus following Palacos (R) cranioplasty in a shunted patient. Br J Neurosurg 2017:1-2. doi: 10.1080/02688697.2017.1317718.  Back to cited text no. 2
Pieri F, Anania CD, Perrini P, Puglioli M, Parenti GF. Delayed otogenic pneumocephalus complicating ventriculoperitoneal shunt. Neurol India 2011;59:616-9.  Back to cited text no. 3
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Sankhla S, Khan GM, Khan MA. Delayed tension pneumocephalus: A rare complication of shunt surgery. Neurol India 2004;52:401-2.  Back to cited text no. 4
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Gonzalez-Bonet LG, Goig-Revert FA, Rodriguez-Mena R, Barcia-Marino C. [Tension pneumocephalus in a patient with a scalp wound and ventriculo-peritoneal shunt: Case report and literature review]. Neurocirugia 2009;20:152-8.  Back to cited text no. 5
Healy J, Grant M, Melnyk S, Boldt B. Tension pneumocephalus-A rare complication of cerebrospinal fluid leak. Radiol Case Rep 2019;14:365-7.  Back to cited text no. 6
Sasani M, Ozer FA, Oktenoglu T, Tokatli I, Sarioglu AC. Delayed and isolated intraventricular tension pneumocephalus after shunting for normal pressure hydrocephalus. Neurology India 2007;55:81-2.  Back to cited text no. 7
Woodhall B, Cramer FJ. Extradural pneumatocele following tantalum cranioplasty. J Neurosurg 1945;2:524-9.  Back to cited text no. 8


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