Ann Thorac Surg 2009;87:1609-1611. doi:10.1016/j.athoracsur.2008.09.008
© 2009 The Society of Thoracic Surgeons
Case Reports
Pneumocephalus After Resection of a Lung Cancer With Posterior Chest Wall Involvement
Matthew J. Schuchert, MDa,*,
Thomas G. Myers, MDb,
John DeGraft-Johnson, MDa,
Ghassan K. Bejjani, MDc,
James D. Luketich, MDa,
Rodney J. Landreneau, MDa
a Division of Thoracic Surgery, Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
b Department of Orthopedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
c Greater Pittsburgh Neurosurgical Associates, Hillman Cancer Center, Pittsburgh, Pennsylvania
Accepted for publication September 2, 2008.
* Address correspondence to Dr Schuchert, Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Shadyside Medical Building, Suite 715, 5200 Centre Ave, Pittsburgh, PA 15232 (Email: schuchertmj{at}upmc.edu).
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Abstract
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Pneumocephalus after resection of intrathoracic tumors is an extremely rare event. A delayed presentation of iatrogenic subarachnoid pleural fistula resulted in symptomatic pneumocephalus after resection of a locally recurrent T4N0 nonsmall cell lung cancer involving the chest wall, T2 to T4 rib heads, and intercostal vertebral foramina. Progressive neurologic decline was noted 3 weeks after discharge. Computed tomography of the head and chest confirmed the presence of an apical pleural space, thoracic subarachnoid air, and pneumocephalus. Immediate clinical improvement followed chest tube decompression of the pleural space.
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Introduction
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The presence of air in the intracranial cavity (pneumocephalus) was first described by Lecat in 1741 [1]. This entity is most commonly encountered in the setting of trauma or infection after craniotomy or spinal surgery. Its association with thoracic surgical procedures has been rarely reported.
A 64-year-old man with a history of a 2.5-cm nonsmall cell lung cancer involving the left upper lobe with visceral pleural involvement (T2N0) treated with lobectomy presented with new left peri-scapular pain and localized 5 cm posterior chest wall recurrence by computed tomography of the chest. The patient underwent treatment with three cycles of platinum-based chemotherapy and 54 Gy of radiotherapy that resulted in a 60% reduction in mass volume as well as resolution of the patient's pain. The residual posterior chest wall mass involving the third and fourth ribs was associated with soft tissue thickening and possible vertebral foramina involvement. A resection was accomplished using a posterolateral thoracotomy, T2 to T4 rib resection, wedge resection of the adherent lung, and T3 to T4 vertebral foramina tumor excision. Intraoperative neurosurgical assistance was obtained during the paraspinal dissection. After resection there was no evidence of residual tumor or evident cerebral spinal fluid leak. A radioactive iodine brachytherapy mesh implant was then positioned over the chest wall margin of resection [2]. The postoperative course was remarkable for a small, persistent air leak requiring prolonged chest tube drainage. The patient was discharged to home with a Heimlich valve on postoperative day 10.
The patient was readmitted 19 days after discharge with failure to thrive, subjective low grade fever with sweats, a mild leukocytosis (white blood cell count, 15,000), and ongoing turbid left chest tube fluid output without air leak. Computed tomography demonstrated a persistent left apical space with central positioning of the pleural catheter within the space. Broad spectrum antibiotics were initiated and plans for thoracoplasty and muscle flap rotation to obliterate the pleural space were contemplated. Two days after hospitalization, the patient was found to be aphasic after an episode of emesis, with right-sided hyperhidrosis and involuntary myoclonic activity in the right hand. The patient remained responsive to all simple verbal commands and the remainder of his neurologic examination was within normal limits. Urgent noncontrast computed tomographic scanning of the brain, neck, and chest demonstrated large intracranial gas collections with mass effect within the cerebral ventricular system, air within the upper cervical and thoracic subarachnoid space, and an apical pleural space (Fig 1). The air was also seen tracking into the paraspinal soft tissues from the apex of the left chest (Fig 2). The patient was immediately transferred to the neurosurgical intensive care unit and placed in a slight Trendelenburg position. Antibiotic prophylaxis against meningitis and encephalitis was initiated. A computed tomographic guided pigtail catheter was introduced into the apical pleural space while the patient was down for the diagnostic imaging. The surgical team also introduced a 14-French arterial embolectomy catheter into the chest tube to de-clot it from proteinaceous debris (Fogarty Occlusion Catheter; Edward Lifesciences, Irvine, CA). When the clot was removed from within the original chest tube, a moderate, continuous air leak was appreciated. The patient's aphasic symptoms immediately improved and the myoclonic activity of his right hand began to resolve by the following morning. The patient's clinical neurologic status had returned to baseline 6 days after the onset of symptoms. Computed tomographic imaging of the brain performed 8 days after symptom presentation showed resolution of the pneumocephalus.
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Fig 1. (A) Computed tomographic scan showing gas seen withinin the ventricular system, subarachnoid spaces, and (B) upper cervical region.
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Fig 2. (A) Computed tomographic coronal and (B) axial images showing air in the spinal canal at the T3 to T4 vertebral foramina.
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A moderate air leak persisted from the chest tubes and on day 9 of this readmission, a repeat posterolateral thoracotomy was performed. Cerebral spinal fluid was found to be seeping from a small area close to the intervertebral foramen from a subarachnoid pleural fistula at the level of the T3 to T4 foramina. Primary repair of the fistula with 5-0 Prolene sutures (Ethicon Inc, Somerville, NJ) was performed, and a pleural flap was mobilized to establish onlay coverage of the dural repair. Fibrin glue was also applied to the area of the repair. Valsalva maneuver did not reveal any residual cerebral spinal fluid leak [3, 4].
A posterior and lateral resection of the first and second ribs was performed. Trapezius and latissimus dorsi muscle flaps were mobilized and transposed over this area of dural repair, the raw surface of the lung, and into the apical space to obliterate it. The procedure was successful in controlling the bronchopleural and subarachnoid pleural fistulae. The apical space was also successfully obliterated. The remainder of the patient's hospitalization was uncomplicated; he was discharged home on postoperative day 22. He remains well 8 months after this final operative repair without neurologic residual.
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Comment
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Pneumocephalus is an uncommon event after thoracic oncologic resection, empyema with bronchopleural fistula, or thoracic exposure to the spine for vertebral corpectomy or other reconstructive spinal surgery [3–5]. The pathophysiologic mechanism of this event is necessarily related to the development of a pleuro-subarachnoid fistula and subsequent egress of intrapleural air through the fistula into the subarachnoid space. As in this case, the source of air under pressure was the combination of positive intrapleural pressure from a tussive or emetic event combined with an uncontrolled bronchopleural fistula and chronic post-resectional pleural space problem.
Cerebral spinal fluid leaks recognized during the primary operation or suspected after the thoracic procedure should alert thoracic and neurosurgeons to the possibility of this potential complication, particularly if pulmonary parenchymal air leak co-exists. Prompt recognition is essential with immediate control of any air leak or space by strategic drainage tube placement, followed by surgical repair of the dural leak, obliteration of any pleural space, and interposition of muscle flaps to avoid potential pneumocephalus related catastrophe from acute neurologic deterioration or ascending meningitis. Thoracic and spinal surgeons should be aware of this potential complication and the principles of management when performing surgery involving the thoracic spine.
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References
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- Jelsma F, Moore DF. Cranial aerocele Am J Surg 1954;87:437-451.[Medline]
- Santos R, Colonias A, Parda D, et al. Comparison between sublobar resection and 125Iodine brachytherapy after sublobar resection in high-risk patients with stage I non-small-cell lung cancer Surgery 2003;134:691-697.[Medline]
- Lin MB, Cheah FK, Ng SE, Yeo TT. Tension pneumocephalus and pneumorachis secondary to subarachnoid pleural fistula Br J Radiol 2000;73:325-327.[Abstract]
- Malca SA, Roche PH, Touta A, Pellet W. Pneumocephalus after thoracotomy Surg Neurol 1995;43:398-401.[Medline]
- Singh RS, Pathak A. Tension pneumocephalus secondary to iatrogenic subarachnoid pleural fistula: certain clarifications Ann Thorac Surg 2002;73:1357.[Free Full Text]
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Abstract
Introduction
