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| LETTER TO EDITOR |
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| Year : 2020 | Volume
: 68
| Issue : 6 | Page : 1488-1489 |
Persisting Postoperative Pneumocephalus after Cranioplasty in Sunken Skin Flap Syndrome
Wen-jian Zheng, Liang-ming Li, Shao-hua Lin
Department of Neurosurgery, Zhongshan City People's Hospital, Zhongshan, Guangdong, China (528403), China
| Date of Web Publication | 19-Dec-2020 |
Correspondence Address:
Dr. Wen-jian Zheng
Department of Neurosurgery, Zhongshan City People's hospital, Sunwen East Road the 2nd, Zhongshan, Guangdong
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.304089
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 |
Sir,
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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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