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Ann Thorac Surg 2002;73:1357
© 2002 The Society of Thoracic Surgeons

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Correspondence

Tension pneumocephalus secondary to iatrogenic subarachnoid pleural fistula: certain clarifications

^a Departments of Cardiothoracic Surgery and Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh-160 012, India

e-mail: medinst{at}pgi.chd.nic.in

To the Editor

We read with interest the article by Bilsky and colleagues [1] documenting 3 cases of tension pneumocephalus, which is a rare complication of iatrogenic subarachnoid pleural fistula. However, we feel that certain facts need to be clarified since the authors have omitted some of the available literature on the subject, including two articles published in this journal [2–4]. (a) The onset of symptoms of pneumocephalus may be as early as the 4th day [3], although most studies report it to be later. (b) It is not uncommon to have pneumocephalus appearing over the cerebral convexity as evident in various articles [2, 3, 5]. The location of the air in the cranium simply depends on the relative position of head and neck during ingress of air in the subarachnoid space. (c) Most of the patients of pneumocephalus respond to conservative treatment, with or without intervention for obliteration of the CSF leak which results in rapid improvement of central nervous system symptoms. However, when there are symptoms of tension pneumocephalus [3] leading to features like the "Mt Fuji" sign [6], intervention in the form of twist drill craniostomy is recommended to relieve the raised intracranial pressure due to air entrapped under tension and produce prompt reversal of symptoms.

References

1. Bilsky M.H., Downey R.J., Kaplitt M.G., et al. Tension pneumocephalus resulting from iatrogenic subarachnoid pleural fistulae: report of three cases. Ann Thorac Surg 2001;71:455-457.[Abstract/Free Full Text]
2. Brown W.N., Symbas P.N. Pneumocephalus complicating routine thoracotomy: symptoms, diagnosis and management. Ann Thorac Surg 1995;59:234-236.[Abstract/Free Full Text]
3. Singh R.S., Pathak A. Tension pneumocephalus after excision of posterior mediastinal mass. Ann Thorac Surg 1999;68:566-568.[Abstract/Free Full Text]
4. Malca S.A., Roche P.H., Touta A., et al. Pneumocephalus after thoracotomy. Surg Neurol 1995;43:398-401.[Medline]
5. D’Addario R., Greenberg J., O’Neill T.J.E., et al. Pneumocephalus: an unusual case. J Neurol Neurosurg Psychiatry 1974;37:271-274.[Abstract/Free Full Text]
6. Sharma B.S., Tewari M.K., Khosla V.K., Pathak A., Kak V.K. Tension pneumocephalus following evacuation of chronic subdural haematoma. Br J Neurosurg 1989;3:381-388.[Medline]

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