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Hellenic Journal of Surgery, 2005, 77, 2 : 585- 590

Tension Pneumocephalus and cervical Pneumorrachis

after blunt chest trauma

Case Report

K.A. Anagnostopoulos, 1 D. Sp. Tsoukalas 1

, Z.C. Fasoulas 2
, E. P.

Intensive Care Unit General Hospital of Karditsa 1 , Department of

Computer tomography G.H. of Karditsa , Forensic medicine Service of
Larissa 3 .

Corresponding Author: Anagnostopoulos Konstantinos


Hellenic Journal of Surgery, 2005, 77, 2 : 585- 590


We report a case of tension Pneumocephalus with cervical

Pneumorrachis of the subarachnoid space and the epidural space, after
blunt chest trauma. The coexistence of thoracic-subarachnoid
communication with the pneumothorax or the pneumomediastinum is
essential for the appearance of this rare complication. In every patient
with blunt chest trauma the possible coexistence of traumatic thoracic-
subarachnoid communication with the pneumothorax or the
pneumomediastinum, must always be seriously considered, in order for
the best available mode of intervention to be selected for the patient.

Intensive Care Unit General Hospital of Karditsa 1 , Department of

Computer tomography G.H. of Karditsa , Forensic medicine Service of
Larissa 3 .

Key Words: Tension pneumocephalus • pneumorrachis • traumatic

subarachnoid – pleural fistula • pneumothorax • pneumomediastinum •
blunt chest trauma.

Hellenic Journal of Surgery, 2005, 77, 2 : 585- 590

The intracranial presence of free air is named pneumocephalus.
Neurological dysfunction which is caused by the increasing intracranial
pressure of free air characterizes the tension pneumocephalus. The presence
of free air in the spinal canal is named pneumorrachis and it can be detected
either in the subarachnoid or in the epidural space.

Pneumocephalus is a rare, but dangerous complication, which is more

frequently evident in intracranial surgical operations or in the case of an open
trauma in the cranium. It has however, been reported as a complication in
thoracic surgery [6, 7, 11], but also in chest trauma [16], as a result of thoracic-
subarachnoid communication.

We report a rare case of tension pneumocephalus and cervical

pneumorrachis of the subarachnoid and epidural space after blunt chest
trauma. A review of literature which includes the pathophysiology, the
presentation, the diagnosis as well as the therapeutic choices, are presented.

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.

Hellenic Journal of Surgery, 2005, 77, 2 : 585- 590

Multiple fractures of the ribs and of the sternum were detected in the chest. The
trachea and the main bronchus were unimpaired, while the lungs did suffer
multiple punctures and there was an extensive rupture of the parenchyma. The
large vessels of the thorax and the heart did not present ruptures. The
examination of the vertebral column did not reveal any fractures.

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.

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

The causes of traumatic communication between the subarachnoid

space and the thoracic cavity are usually injury or surgical intervention in the
thorax. Lloyd and Sahn (2002) [1], during the examination of all published
cases of subarachnoid – pleural fistulas (Subarachnoid-pleural fistula - SPF),
found that blunt chest trauma constituted the cause for the creation of
traumatic fistulas in 14 of the 30 cases (46%). The trauma (blunt and
penetrating) was the cause of traumatic fistulas in 77% of the cases. The
other cases are met as complications after transthoracic diskectomy and
thorax surgery.

As regards to the type of traumatic fistulas, Sarwal (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

Traumatic fistulas can rarely cause pneumocephalus or even

pneumorrachis. Ristagno (2002) [3] report the existence of two published
cases where this complication was developed, after blunt chest trauma.

The mechanisms with which the traumatic fistulas are created have an
immediate relationship with the mechanism of trauma [2]. Blunt trauma, in the
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.

Pneumorrachis of the epidural space by itself is usually innocuous and

self-limited [5].

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
presents sudden neurological deterioration, the existence of pneumocephalus
should be examined.

The diagnosis of pneumocephalus and pneumorrachis is usually very

obvious on a CT – scan [14], but it can also be detected with an MRI - scan or
even with simple x-rays [3]. The investigation of this rare complication includes
the imaging ascertainment of pneumothorax or pneumomediastinum with
simple x-rays or a CT - scan and the proof of SPF.

The detection of Beta - 2 - tranferrin, with the electrophoresis of

pleural fluid is indicative of the presence of CSF and diagnostic for the
existence of SPF [4, 10, 11]. In the case of patients with hemopneumothorax,
the detection of CSF may be problematic [2].

Definite identification of a fistula is confirmed radiographically. The

method of choice to prove SPF is water-soluble myelography that is followed
by CT - scanning [1, 2, 6, 13]. This gives information with regards to the
location, the length of SPF and the anatomy in the region of lesion. In patients
with a low flow of fistula, the radioisotope myelography can confirm the
diagnosis, without giving information regarding the anatomy of the region [2, 4,

The treatment of pneumocephalus depends on either the obliteration

of the spinal fluid leak or the resolution of pneumothorax. The presence of
pneumothorax, the size of the fistulous tract, as well as the time that
intervenes until the appearance of the symptoms affect the treatment choices.

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, (1986) [16] achieved the reprocess pneumocephalus with the
use of suction for the removal of intrathoracic air. Bilsky, (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.

There is no consensus for the management of subarachnoid-pleural

fistulas. The appropriate timing for surgical intervention is unknown and
absolute indications for operation are not clear. Pollack, (1990) [17]
propose early surgical intervention for the repair of traumatic fistulas. Sarwal, (1996) [ 2 ] include recurrent and increasing size of CSF flow, persistent
symptoms or the removal of a foreign body that causes the S.P.F. as
indications for surgical intervention. The last one is considered to be the main
indication for emergency surgical intervention. The strategy that indicates
spontaneous closure of SPF with decompression of subarachnoid space via
closed drainage, with simultaneous presence of pneumothorax is a uncertain
practice [6, 9, 15].

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

Special thanks to Dr. Dimitrios Balkizas (Radiologist) for

his useful input and to Mr.Chalatzakos for his technical

Hellenic Journal of Surgery, 2005, 77, 2 : 585- 590


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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.

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.

Fig. 3: CT-scan of the thorax (pulmonal window) demonstrating:
Subcutaneous and intramuscular emphysema of thoracic wall. Bilateral
tension hemopneumothorax and pneumomediastinum.