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Case Report
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Abstract
Case Report
A 36 year old male worker was transferred to the emergency room of
the General Hospital of Karditsa, with a blunt chest trauma, that was caused
by a fallen rock. In the beginning he was diagnosed with respiratory
insufficiency, hypovolemic shock and a low level of consciousness, having a
Glasgow Coma Scale (GCS) of 12.
After the urgent intubation of the patient and the exercise of positive
pressures, he expressed sudden neurological deterioration, having a GCS of
6. His ophthalmus initiated paresis (uncoordinated movements of the
eyeballs) while his pupils presented automatic alternations of their size
(alternately mydriasis and mysis).
The status of the patient was initially stabilized with massive fluid
administration (crystalloid and colloids) and the bilateral placement of two
chest tubes in the thoracic cavity. During the CT – scan, the following
investigations were detected: tension pneumocephalus (fig. 1), cervical
pneumorrachis of subarachnoid and epidural space (fig. 2), as well as bilateral
tension hemopneumothorax, pneumomediastinum, multiple fractures of the
ribs and a gap in the thoracic cavity (fig. 3).The patient died during transport to
the Intensive Care Unit (I.C.U).
The autopsy detected a small fracture of the right anterior cranial fossa,
while the dura mater did not present any damage. The brain presented a
macroscopic picture of edema. There was no macroscopic damage detected
in the parenchyma of the brain and in the cerebellum. The hexagon of Willis
was normal. Moreover, the anatomy of the neck did not present any damage.
The organs of the abdominal cavity did not present injuries. The death
of the patient was attributed to the heavy thoracic injury in combination with
severe traumatic brain injury.
Taking all of the above into consideration, coupled with the imaging and
the findings of the autopsy, we suppose the existence of thoracic-
subarachnoid communication. So the puncture and the extensive rupture of
pulmonary parenchyma allowed the direct transport of positive pressures that
were exercised after the intubation in the intrapleural air. The increase of
intrapleural pressure caused the increase of the intracranial pressure, which
was expressed with a change of the neurological picture and which probably
led to the celebral edema.
Discussion
The appearance of pneumocephalus or a combination of
pneumocephalus and pneumorrachis after blunt chest trauma presupposes
the coexistence of traumatic communication between the subarachnoid space
and the thoracic cavity and simultaneously the presence of free air in the
thorax.
As regards to the type of traumatic fistulas, Sarwal et.al (1996) [2], after
having studied the published cases of traumatic SPF, found that there are
three types of traumatic fistulas:1) The subarachnoid - pleural fistula, which is
more common, 2) the subarachnoid - extrapleural fistula and 3) the
subarachnoid - mediastinal fistula. These types of traumatic fistulas may
coexist.
The mechanisms with which the traumatic fistulas are created have an
immediate relationship with the mechanism of trauma [2]. Blunt trauma, in the
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case of automobile accidents, is probably due to extreme extension of the
spine, resulting in the tearing of relatively immobile thoracic nerve roots and
durra. In case that a great amount of compression is exercised above the
chest wall, this can lead to the perforation of the pleura against the osteoid
ledge of vertebra. This, coupled with tearing of nerve roots, results in the
creation of communication. We suppose that this mechanism happened in our
patient. Thirdly, sharp fracture of segments of the spine may lacerate both the
pleura and the dura mater.
The mechanism with which air is transported from the pleural space to
the subarachnoid space is not absolutely explicit. The subarachnoid - pleural
fistula remains open and allows the exit of cerebrospinal fluid (CSF) because
of the presence of pressure gradient that is created by the positive pressure of
CSF (50-180 mm H2O) and sub atmospheric (negative) intrapleural pressure,
in all of the phases of breathing. The presence of air in the pleural cavity
renders the intrapleural pressure less negative and when this exceeds the
atmospheric pressure, it causes tension pneumothorax. Under these
conditions, it is expected that the transport of air in the subarachnoid space
will happen while the intrapleural pressure exceeds the pressure of CSF. The
placement of the head in an upright position allows for air to move itself
cephalic, resulting in the creation of pneumocephalus. The air, transported via
SPF, is mainly distributed in the ventricles and the basilar cisterns of brain [6].
The transport of air in the epidural space of the vertebral column usually
happens with two following mechanisms [3]. Atmospheric air passes through a
spinal needle into the epidural space. In the other case, if air is present in the
posterior mediastinum, it may dissert along fascial planes from the posterior
mediastinum (or retropharyngeal space) through nervous foramina, and into
the epidural space. Mediastinal air moves into the epidural space behind the
driving pressure of a tension pneumothorax or pneumomediastinum.
Common symptoms which are detected with the loss of CSF, due to the
existence of SPF are headaches, nausea and vomiting [8]. When an increased
loss of CSF is detected, disturbances of mental status and symptoms
generated by cranial nerves and brain stems, as well as dysfunction of the
cerebellum, are observed [9]. The events that are reported in symptomatic
pneumocephalus, which is related to the presence of SPF, include headaches
and disturbances of the level of consciousness, lethargy and confusion.
Finally, focal neurological symptoms, such as hemiplegia, aphasia, gait ataxia
and dysmetria may also occur, mimicking a stroke [6], as well as disturbances
of eyesight [7].
A high degree of suspicion is required to establish the diagnosis of
pneumocephalus. Frequent symptoms due to the intracranial presence of air
may be minimal or overshadowed by concomitant injuries and often the
diagnosis may be delayed. In each patient with traumatic pneumothorax who
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presents sudden neurological deterioration, the existence of pneumocephalus
should be examined.
The removal of free intrathoracic air with the use of suction, so that
the reprocess pneumocephalus is achieved, depends on the rate of loss of air.
Mc Call, et.al (1986) [16] achieved the reprocess pneumocephalus with the
use of suction for the removal of intrathoracic air. Bilsky, et.al. (2001) [6],
propose conservative management with bed rest, flat head position and
removal of the chest tube from the suction. In the case of patients with a
continuous loss of air who needed continuous suction via the chest tube or
when SPF remains open for more than two weeks, surgical repair is proposed.
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Pneumocephalus, after blunt chest trauma, is a rare but likely
complication. In every patient with blunt chest trauma, the possible
coexistence of traumatic thoracic-subarachnoid communication with the
pneumothorax or pneumomediastinum, must always be seriously considered,
in order for the best available mode of intervention to be selected for the
patient.
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References
5. Cauter MI
Cervical Surgical Emphysema Following extradural analgesia
Anaesthesia , 1984 , 39: 1115- 1116
8. Frederick A. Zeller
Pleurodural Fistulas and Neurologic manifestations.
Jaber Monla- Hassan and Robert Hyzy
Pleurodural Fistulas and Neurologic manifestations (letters)
Chest 1999 , 116 (2): 584-5
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Clin.Nucl. Med. 1999 , 24: 985-986
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Fig. 1: Axial non-contrast CT-scan of the head at the level of lateral
ventricles demonstrating: Air in the subarachnoid space of the frontal
lobes, as well as air in the frontal horns of the lateral ventricles, under
tendency (alteration of the physiologic convexity of lateral ventricles).
Tension pneumocephalus.
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Fig. 2: CT-scan of the neck at the level of larynx demonstrating: Air in
the spaces of the neck, as well as air in the retropharyngeal space. In
the same section, air in the subarachnoid space of cervical spinal canal
and air inside of the epidural fat. Pneumorrachis of the subarachnoid
space and the epidural space.
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Fig. 3: CT-scan of the thorax (pulmonal window) demonstrating:
Subcutaneous and intramuscular emphysema of thoracic wall. Bilateral
tension hemopneumothorax and pneumomediastinum.
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