Ann Thorac Surg 1999;68:566-568
© 1999 The Society of Thoracic Surgeons
Case Reports
Tension pneumocephalus after excision of posterior mediastinal mass
Rana Sandip Singh, MCha,
Ashis Pathak, MChb
a Department of Cardiothoracic Surgery , Postgraduate Institute of Medical Education and Research, Chandigarh, India
b Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Address reprint requests to Dr Singh, H.No. 2113, Sector 38-C, Chandigarh-160 023, India
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Abstract
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Although paraplegia after a posterolateral thoracotomy has been described as a serious complication, the occurrence of tension pneumocephalus after excision of posterior mediastinal mass has also been reported as another life-threatening complication. We report one such case.
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Introduction
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Paraplegia is an uncommon but dreaded neurologic complication after posterolateral thoracotomy [1]. Pyogenic meningitis after such an approach has also been reported [2]. We report a rare complication, tension pneumocephalus, encountered after excision of posterior mediastinal mass through a posterolateral thoracotomy.
A 40-year-old man presented with diffuse pain in the upper dorsal region. Computed tomographic scan revealed a mass on the right side in the posterior mediastinum with no intraspinal extension (Fig 1). Excision of the tumor was done through a posterolateral thoracotomy. Thin fibrinous adhesions between the lung and the tumor could be separated easily without obvious damage to the lung or any air leak. The underling vertebral body appeared eroded. There was no evidence of metastasis. Although the surgical procedure seemed uneventful, the intercostal tube drainage during the first 24 hours was 750 mL of blood-tinged watery fluid. Subsequently, it decreased significantly to enable removal of the tube 72 hours postoperatively. Results of histopathologic examination of the tumor were consistent with neurofibroma. On the fourth postoperative day the patient had headaches and weakness in both lower limbs. He was drowsy, incontinent to urine, but afebrile. Neurologic examination revealed increased tone in both the lower limbs with power of grade 4 to 5 and a bilateral extensor plantar response. Computed tomographic scan of the head revealed bilateral tension pneumocephalus (Fig 2). There was no radiologic evidence of pneumothorax at this stage.
A frontal twist drill tap was done and about 150 mL of air was evacuated using a three-way cannula. The patient improved after the tap and was discharged on 12th postoperative day in ambulatory condition. He has no neurologic deficits at follow-up of 1 year.
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Comment
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Pneumocephalus is common after head trauma. Neoplasms, infections, sinus operations, or other intracranial procedures constitute other important causes [3]. Pneumocephalus after elective thoracic surgery is rare. Injury to the dural sleeve of the emerging intercostal nerve occurs either by traction on the tumor during its dissection, excessive rib retraction, or by fracture of the rib, leading to the development of subarachnoid pleural fistula [3].
Manipulation of the tumor in the present case might have lead to an inadvertent tear in the dura resulting in leakage of cerebrospinal fluid which manifested as excessive intercostal tube drainage during the first 24 hours postoperatively. A small air leak from the lung, which went undetected, replaced the cerebrospinal fluid. Subsequent healing of subarachnoid pleural fistula led to cessation of cerebrospinal fluid leak in 48 hours. High tension in a relatively small pneumothorax is known to occur when the lung is adherent to most of the chest wall with a persistent small pocket of air [3]. The air migrates to the cranium once the patient can sit upright. The neurologic effects of air under pressure in the cranial subdural space were reversed by evacuation of air through a twist drill tap. A decompressive ventricular puncture is advocated in cases of tension pneumocele with neurologic impairment [4].
Apart from the nonspecific features of increased intracranial pressure, the most characteristic physical sign is the presence of bruit hydro-aerique, which is a splashing sound evoked by rapid change in head position. Although a computed tomographic scan of the head confirms the presence of a subarachnoid pleural fistula, other methods of diagnosis consist of the detection of central nervous system–specific ferritin in the chest drain or finding fluorescein or indigocarmine dye in the thoracostomy tube after subarachnoid injection. Postmyelographic computed tomographic scanning can localize the anatomic level and extent of fistula [5].
The subarachnoid pleural fistula diagnosed intraoperatively can be repaired either by simple ligation or by using vascularized muscle pedicle, free muscle graft, or free fat graft. Fibrin glue, bone wax, or methyl methacrylate can also be used as sealant but can lead to paraplegia by spinal cord compression when used in excess. Paraplegia after the use of oxidized cellulose or gelfoam near posterior foramina has been reported [6]. A fistula detected postoperatively warrants a trial of conservative treatment, as 27% of them heal spontaneously, as in the present case. Should the fistula persist, direct operative intervention is required to prevent brain herniation and death [7]. Spinal drainage could also be considered an initial therapeutic modality [4].
Thorough understanding of anatomy, gentle tissue handling, and avoidance of excessive retraction of ribs during transthoracic procedures can prevent the occurrence of this complication. Early recognition and prompt treatment can help most patients recover without any sequelae, should this rare complication occur.
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References
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Accepted for publication January 9, 1999.
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Abstract
Introduction
