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Ann Thorac Surg 2001;71:455-457
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Tension pneumocephalus resulting from iatrogenic subarachnoid–pleural fistulae: report of three cases

^a Division of Neurologic Surgery, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
^b Division of Thoracic Surgery, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
^c Department of Neurosurgery, Beth Israel Medical Center, New York, New York, USA

Accepted for publication August 23, 2000.

Address reprint requests to Dr Bilsky, Division of Neurosurgery, Memorial Sloan-Kettering Cancer Center, Box 71, 1275 York Ave, NY, NY 10021
e-mail: bilskym{at}mskcc.org

Background. Symptomatic pneumocephalus may result from a cerebrospinal fluid leak communicating with extradural air. However, it is a rare event after thoracic surgical procedures, and its management and physiology are not widely recognized.

Methods. During the past 2 years, we have identified 3 patients who developed pneumocephalus after thoracotomy for tumor resection. Only 1 patient had a discernible spinal fluid leak identified intraoperatively. Two patients experienced delayed spinal fluid drainage from their chest tubes and subsequently developed profound lethargy, confusion, and focal neurologic signs. The third patient was readmitted to the hospital with a delayed pneumothorax and altered mental status. Radiographic imaging in all patients showed significant pneumocephalus of the basilar cisterns and ventricles.

Results. The first 2 patients were managed by discontinuation of the chest tube suction and bedrest. The third patient underwent surgical reexploration and nerve root ligation. All 3 patients had resolution of their symptoms within 72 hours.

Conclusions. Pneumocephalus is a rare, but serious, complication of thoracotomy. Previous patients reported in the literature have been managed with reoperation to ligate the nerve roots. However, the condition resolved nonoperatively in 2 of our patients. Discontinuation of chest tube suction may be definitive treatment and is always the important initial management to decrease cerebrospinal fluid extravasation into the pleural space and allow normalization of neurologic symptoms.

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