Neurocrit Care

DOI 10.1007/s12028-017-0464-x

REVIEW ARTICLE

Oxygen Therapy with High-Flow Nasal Cannula as an Effective

Treatment for Perioperative Pneumocephalus: Case Illustrations
and Pathophysiological Review
Jason L. Siegel1,2 • Karen Hampton3 • Alejandro A. Rabinstein4 •

Diane McLaughlin2 • Jose L. Diaz-Gomez2,5,6

Ó Springer Science+Business Media, LLC 2017

Abstract Pneumocephalus (PNC) is a condition in which of high-flow nasal cannula (HFNC), all patients improved
when air is trapped inside the intracranial vault. The causes both clinically and radiographically within a few hours,
are varied, but include trauma and intracranial surgery. faster than in both anecdotal experience and published
Treatment of PNC typically consists of augmenting patient trials. Due to its steady FiO2 administration, positive
oxygenation with the attempt of washing out pulmonary pressure, comfort, and low side-effect profile, HFNC may
nitrogen, creating a gradient in which nitrogen in the be the ideal mode of oxygen delivery in PNC. We present a
intracranial air bubble diffuses out of the lungs via the review of the physiology of PNC and the characteristics of
blood. Though several high flow methods have been tested, several oxygen delivery systems to build a case for HFNC
the ideal mode of oxygenation has not fully been investi- in this disease process.
gated. Here we present 3 cases of post-operative PNC who
we felt were symptomatic from PNC. With administration Keywords Tension pneumocephalus 
High-flow nasal cannula  Craniectomy  Oxygen therapy 
Arterial oxygen partial pressure
& Jason L. Siegel
Siegel.jason@mayo.edu
Karen Hampton Introduction
Hampton.karen@mayo.edu
Alejandro A. Rabinstein Pneumocephalus (PNC) is a condition in which air enters
Rabinstein.alejandro@mayo.edu
and is contained inside the intracranial compartment. It has
Diane McLaughlin been studied and well described for over 100 years [1–5].
Mclaughlin.diane@mayo.edu
PNC can be caused by head and facial trauma,
Jose L. Diaz-Gomez intracranial and spinal procedures (including lumbar
Diazgomez.jose@mayo.edu
puncture), otorhinolaryngological procedures, and even
1
Department of Neurology, Mayo Clinic, 4500 San Pablo spontaneously. When intracranial pressure (ICP) increases
Road, Jacksonville, FL 32224, USA causing neurological decline, PNC is referred to as tension
2
Department of Critical Care, Mayo Clinic, Jacksonville, pneumocephalus (TP). Symptoms can include nausea,
FL 32224, USA vomiting, seizures, dizziness, and altered mental status
3
Department of Respiratory Therapy, Mayo Clinic, [5, 6].
Jacksonville, FL 32224, USA Here, we present three cases of postoperative PNC
4
Department of Neurology, Mayo Clinic, Rochester, which resolved quickly with humidified oxygen delivery
MN 55905, USA via high-flow nasal cannula. We follow the cases with a
5
Department of Anesthesia and Perioperative Medicine, Mayo detailed review of the mechanisms and pathophysiology of
Clinic, Jacksonville, FL 32224, USA PNC and its treatment, as well as future directions in
6
Department of Neurosurgery, Mayo Clinic, Jacksonville, management.
FL 32224, USA

123

Fig. 1 a Axial magnetic resonance imaging T1 with gadolinium
contrast revealing multiple falcine and left convexity meningiomas
with vasogenic edema of the left frontal lobe. b Axial computed
tomography scan revealing left frontal pneumocephalus with efface-
ment of the left frontal sulci, edema, and 8 mm left-to-right midline
shift. c Axial computed tomography scan showing improvement in
midline shift and nearly improvement in the PNC. d Axial noncon-
trast head CT demonstrating air within the surgical bed of the right
frontotemporal resection. e Axial noncontrast head CT showing
bifrontal PNC with air between the frontal tips, due to greater pressure
Case Reports
Case 1
A 78-year-old woman was presented with focal seizures
and multiple convexity and falcine meningiomas (Fig. 1a).
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Neurocrit Care
of air than the surface tension of cerebral fluid between the frontal
lobes (known as the Mount Fuji sign). There is also bifrontal sulcal
effacement. f Axial FLAIR Magnetic resonance imaging (MRI) of the
same cut as the B., with resolution of the PNC. g Axial noncontrast
head CT demonstrating bilateral subdural hematomas. h Axial
noncontrast head CT showing bifrontal air bubbles without commu-
nication between them. i Axial noncontrast head CT with
improvement in bilateral PNC after 20 h of HFNC therapy
She underwent hemicraniotomy for removal of the masses.
Postoperatively, she was aphasic with right hemiplegia and
sensory loss. Noncontrast head computed tomography (CT)
showed left-sided pneumocephalus causing 8 mm left-to-
right shift (Fig. 1b). Electroencephalogram (EEG) showed
left hemisphere slowing, but no seizures or epileptiform
Neurocrit Care
discharges. She was put on 100% oxygen via 15 L/min
nonrebreather (NRB) mask. Bedside lung ultrasound and
chest X-ray did not reveal interstitial pulmonary edema or
pleural effusion, and her SpO2 was 97% with ongoing
encephalopathy. Oxygen therapy was changed to humidi-
fied oxygen via high-flow nasal cannula (HFNC) at 30 L/
min, and fraction of inspired oxygen (FiO2) of 1. Her
arterial oxygen partial pressure (PaO2) increased from
162.5 to 410.6 mmHg, and her neurological deficits dra-
matically improved. Repeat head CT 16 h later showed
reduced PNC with midline shift reduced to 6 mm (Fig. 1c).
Her depressed alertness, aphasia, weakness, and sensory
loss were likely due to the TP, as there were no alternative
explanations and her neurological condition improved
rapidly with improvement in the PNC. We postulate that
the increased PaO2 via high-flow nasal cannula helped to
reduce the intracranial air, thus improving her symptoms.
Case 2
A 57-year-old woman with history of right mesial tem-
poral sclerosis and subsequent drug resistant localization
related epilepsy underwent right anterior temporal lobec-
tomy for ongoing seizures. Postoperatively, she was alert,
oriented, and fully attentive. Approximately 6 h later, she
developed signs of hyperactive delirium, manifested by
restlessness, disinhibition, inattention, echolalia, and per-
severation. Noncontrast head CT revealed PNC around
the surgical bed as well as the bifrontal areas, with the
Mount Fuji sign (Fig. 1d, e). HFNC oxygen therapy at
30 L/min at FiO2 of 1 was initiated with subsequent
resolution of her cognitive deficits and near complete
resolution of her PNC within 12 h. By the next morning,
she had clinically returned to baseline with resolution of
the PNC on follow-up magnetic resonance imaging 12 h
after the head CT (Fig. 1f).
Case 3
A 58-year-old male with history of sarcoidosis of the liver
and coagulopathy presented with headache and gait insta-
bility. He had bilateral spontaneous subdural hematomas
(Fig. 1g) and underwent bilateral burr-hole evacuation. An
immediate postoperative noncontrast head CT showed
bilateral PNC with compression of both frontal lobes
(Fig. 1h). He was somnolent, but his neurological exami-
nation was otherwise unremarkable. High-flow nasal
cannula at 20 L/min at FiO2 of 1 was administered. Twenty
hours later, repeat noncontrast head CT showed improve-
ment in the air pockets and he returned to his neurological
baseline (Fig. 1i).
Pathophysiology of Pneumocephalus
Air enters the intracranial vault in two ways, depending on
the pressure gradient across the skull defect: Air can be
pulled into the skull by negative intracranial pressure (ICP)
or pushed in by positive extracranial pressure (ECP). In
addition, the nature of the skull defect determines how the
air becomes trapped. Together, these principles distill into
two basic models of PNC: the inverted bottle model and the
ball-valve model [7].
In the inverted bottle model, an intra-extracranial cere-
brospinal fluid (CSF) fistula is created. When ICP exceeds
ECP, the CSF leaks out of the skull through the fistula until
the pressures equalize [7]. If ICP then decreases due to
reduced brain edema, positioning (higher than 30°),
increased CSF resorption, decreased venous pressure,
absorption of hemorrhage, or decreased CSF production, a
negative gradient relative to ECP develops, which facili-
tates the movement of air into the skull through the fistula.
The air collects at the top of the intracranial vault in a
gravity-dependent manner creating a water seal. If any of
these situations reverses and ICP increases, CSF rather than
air will escape the head (Fig. 2a).
In the ball-valve model, the skull defect is sealed by a
dural flap. This dural flap may temporarily allow the inflow
of air when the ICP decreases, but subsequently prevents
the escape of either air or CSF with increases in ICP
(Fig. 2b).
Postsurgical intracranial air can be caused by either of
these models through imperfect closure. Additionally, air
can be sealed into the intracranial vault during surgical
closure, even though at that time there is no pressure gra-
dient. In this latter instance, because there is no pressure
gradient, the risk of developing a TP is lower without
additional inverted bottle or ball-valve effect.
Physiological Model for Treatment
Due to the inverted bottle and ball-valve models, air cannot
evacuate the intracranial vault. Thus, for PNC resolution,
air must be carried out by the circulating blood. Gases
diffuse into the blood following Fick’s law:
0
Vgas ¼ ðDcoef  A  DPÞ=T
[Volume of gas transferred per unit time = Diffusion
coefficient of the gas 9 surface area 9 partial pressure
difference of the gas)/thickness of the membrane].
The intracranial gas bubble should have the same gas
components as atmospheric and alveolar air [*79%
nitrogen (N2), *21% oxygen (O2)]; therefore, there will
be no functional gradient of these gases within the skull
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Fig. 2 Mechanisms of air introduction and entrapment in the intracranial vault due to the two basic models: inverted bottle and ball valve
and the lungs, and no gas transfer will occur. Of these two
primary gases, nitrogen will have the larger volume and,
thus, removing it will have the most impact. Of the vari-
ables of Fick’s law, we have the most control over DP, the
partial pressure difference of N2. Increasing FiO2 to 1 will
decrease the N2 partial pressure in the alveoli (PpN2),
creating a concentration gradient with the blood, and ulti-
mately a concentration gradient with the intracranial air
bubble. Nitrogen should diffuse from the intracranial
bubble to the blood, and out the lungs. At all levels of
oxygen therapy, most intracranial air is absorbed in the
initial periods of oxygen therapy, especially with moderate
or large PNC [8]. Using mathematical models, Dexter and
Reasoner demonstrated that increasing FiO2 should make a
significant improvement in PNC volume over time [9], but
that the effect may plateau at about FiO2 0.5.
Although Dexter’s models predict that increasing PaO2
(via increasing FiO2) would have a ceiling in its beneficial
effect to reduce PNC, there is another mechanism by which
high PaO2 can promote N2 clearance. Increasing PaO2 will
force O2 into the intracranial air bubble, further washing
out the N2. On room air (FiO2 0.21), the partial pressure of
O2 in the intracranial bubble will be that of the atmosphere
(*150 mmHg), which is more than in blood
(PaO2 * 95 mmHg). This gradient favors diffusion of
oxygen from the intracranial air bubble to the blood, but
such gradient can be reversed by increasing PaO2. Thus,
increasing FiO2 to 1 and PaO2 to >400–500 mmHg (in
normal human lungs) reverse the partial pressure gradient
favoring O2 into the air bubble, forcing N2 into the blood.
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Importantly, based solely on the physiology and theo-
retic basis of PNC washout, other factors can play a role in
air accumulation and reabsorption, making it difficult to
predict the rate of air bubble resolution.
Current Treatment Strategies
A conservative approach for the treatment of PNC is
decreasing ICP by placing the patient at 30° and avoiding
ICP spikes and CSF leakage spikes by limiting Valsalva
maneuvers, sneezing, coughing, or straining from pain.
Yet, PNC may take 2–3 weeks for resolution with these
measures only [10], and conservative management is not
appropriate when patients are symptomatic from increased
ICP.
The mainstay of conservative PNC treatment is aug-
mented oxygen delivery. The modes of oxygen delivery
vary, however, in flow rate, FiO2 delivery, invasiveness,
and patient comfort (Table 1) [11, 12]. Providing oxygen
therapy with 100% inspired oxygen is recommended for
symptomatic patients. This treatment hastens the resorption
of air by increasing the washout of N2. There are currently
no consensus guidelines on the optimal way to administer
oxygen therapy, including FiO2, mode of delivery, and
duration of delivery.
The first prospective trial for normobaric oxygen ther-
apy compared oxygen therapy with 100% O2 via NRB for
24 h against room air in patients with postoperative PNC
(at least 30 ml or greater). The study found a significant
Neurocrit Care

Table 1 Summary of the available reports of PNC treatment modalities

Method FiO2 delivery (%) Flow (L/min) Comments

Low-flow systems—delivers O2 100% flows less than patient’s inspiratory flow rate
Nasal cannula 24–44 1–8 Not recommended for severe hypoxia due to inconsistent FiO2
Humidification recommended when >4 L/min
Face mask 35–50 >5 Nonspecific FiO2
Mask reservoir 40–60 5–10 Flow rate > 5L/min improves washout of gas.
Mask can be obtrusive, uncomfortable, obstructs coughing
Cannot administer humidified air
Nonrebreather 40–90 8–15 Mask must be tightly sealed
Uncomfortable and drying
Risk of CO2 retention if mask reservoir allowed to collapse
High-flow systems—delivers O2 100% flows greater than patient’s inspiratory flow rate
Venturi mask 24–40 4–12 Accurate and consistent FiO2
Used with CO2 retention and inconsistent respiratory drive
OxyMask 24–80 1–15 Open system avoids accumulation of CO2
Comfortable
High-flow nasal cannula Up to 100% 10–60 Heat and humidified O2
Provides small amount of PEEP
Increased flow may expedite N2 washout from the lungs
CO2 carbon dioxide, FiO2 fraction of inspired oxygen, O2 oxygen, PEEP positive end-expiratory pressure

improvement in mean rate of volume reduction (65 vs.
31%, p = 0.009) over 24 h [13].
Another study of patients with postoperative PNC and
bubble volumes C30 ml found that normobaric hyperoxy-
genation for only 3 h via an endotracheal tube also reduced
CT air volume and improved patient alertness [14]. This
study highlights that gas diffusion may occur so quickly
that we can get meaningful results within a few hours of
initiating treatment.
One study prospectively compared normobaric oxy-
genation with hyperbaric oxygenation of 2.5 atmospheres
(atm) in 24 patients with symptomatic PNC. Patients in the
hyperbaric oxygen group improved clinically and radio-
graphically more rapidly than the controls (time to
resolution 3.0 vs. 8.3 days, p = 0.01), and had shorter
hospital stays (5.8 vs. 9.9 days, p = 0.01) [15]. The
authors postulated that hyperbaric oxygen (HBO2) has a
greater effect on elevating PaO2, thus accelerating N2
washout [15]. However, this study did not report PaO2
levels, and hyperbaric chambers are often not available.
Furthermore, HBO2 has also been reported as a potential
cause of PNC [16].
In some cases, drilling burr holes, needle aspiration, and
surgical closure of the dural defect may be necessary,
especially in TP. Ideally, the surgical management should
be tailored to the pathophysiological mechanism. For
instance, sinus surgery is also commonly treated with sinus
packing and surgical repair of the dural tear as these fistulas
are especially susceptible to the effects of Valsalva
[10, 17]. Other preventive measures after excision of brain
tumors include drain placement at the end of the procedure
and keeping the patient in the supine position during the
initial postoperative recovery.
In reviewing the literature, we did not find high-level
evidence for the management of PCN. Reported treatment
strategies are summarized in Table 2 [8, 13–15, 17–19].
Potential Utilization of HFNC as a Novel Strategy
in Conservative Treatment of PNC
Although NRB is most commonly used for the treatment of
PNC, HFNC offers heated and humidified, higher flow rate,
with more consistent FiO2 delivery (0.21–1.0), and is less
invasive and more comfortable than NRB (Fig. 3). High-
flow devices without heated or humidified delivery source
(via regular nasal cannula or NRB) can be irritating to the
nasal mucosa and prolonged use can become uncomfort-
able for the patient. The system does not require large
machinery and is easily assembled by a respiratory thera-
pist. There have been no studies, however, directly looking
at HFNC or comparing HFNC with NRB in the treatment
of PNC.
HFNC may help respiratory mechanics by improving
ventilation and increasing oxygenation. In healthy human
subjects, HFNC was shown to increase tidal volume and
decrease respiratory rate proportionally to the delivered

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Table 2 Comparative features of various modes of oxygen delivery

Authors; Number of patients; Intervention Control Primary Notable secondary Comments
year type of study outcome outcomes

Arbit et al. 1; case report Controlled N/A Resolution of N/A The patient was
[16] decompression neurological initially treated
via a closed decline and with NRB with
water-seal decrease in NCHCT
drainage intracranial air resolution, but
after 4 days PNC re-emerged
4 days later
requiring drainage
Reasoner 134 postoperative N/A N/A PNC seen on Moderate or large Authors do not
et al. [8] intracranial NCHCT: PNC on scans: comment on
procedures; 100% POD#0 66% POD #0 treatment
retrospective, and #2 75% 11.8% POW#2 modalities
observational POW #1
59.6% POW #2
26.3% POW#3
Gore et al. 13 postoperative PNC 100% O2 using Room air for Mean rate of No safety First prospective
[11] (C30 m); prospective NRB at 12 24 h radiographic differences study examining
RCT L/min for 24 h volume effect of
reduction: supplemental O2
intervention on PNC resolution
65% versus
control 31%
(p = 0.009).
DelGaudio 10 (8 after endoscopic N/A N/A 7/10 patients All underwent No comment on
and sinus surgery, 2 after resolved with surgical re- what was
Ingley microscopic skull ‘‘conservative exploration, 8 ‘‘conservative
[15] base surgery); management’’ needed defect management’’
retrospective repair, 2 had
scarring not
requiring repair
Chung 1; case report Mechanical Complete Patient remained
et al. [17] ventilation, Vt resolution of intubated for
450 ml, FiO2 PNC by day 3 3 days
100%
Paiva et al. 24 (22 traumatic, 2 HBO2 at 2.5 atm, 5 L/min NC for Time to Time of HBO2 not available
[13] postoperative); 100% O2 for 1 h 5 days radiographic hospitalization: at many sites
prospective RTC once or twice resolution controls (days) HBO2 has been
daily for 5 days, (days): 9.9 versus HBO2 implicated in
or until controls 8.3 5.8 (p = 0.01) causing PNC [13]
radiographic versus HBO2
resolution of 3.0 (p = 0.01)
PNC
Hong et al. 44 postoperative Ongoing Weaned off Change mean air Mean air resorption Only 3 h of
[12] supratentorial PNC endotracheal sedation and volume (mL): rate (mL/h): 0.63 treatment needed
(>30 ml) after intubation extubated -16.54 in the faster in the
posterior fossa following postoperatively intervention vs intervention
surgery in the surgery with control group
semisitting position. FiO2 100% for (p = 0.001) (p = 0.0015)
Patients enrolled after 3h
immediate
postoperative head
CT
Prospective RTC
Atm atmospheres, HBO2 hyperbaric oxygen, N/A not applicable, NC nasal cannula, NCHCT noncontrast head CT, PNC Pneumocephalus, POD
postoperative day, POW postoperative week, RTC randomized controlled trial, Vt tidal volume

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Neurocrit Care
Fig. 3 High-flow nasal cannula system used in our facility is by
Fisher and Paykel. This setup consists of: a MR850 heater with dual
temperature probe and heater wire adapter; b RT219 bi-level heated
limb circuit with the MR290 chamber; c patient interface is the F&P
Optiflow + Nasal Cannula; d blended oxygen source with a
0–70 lpm flowmeter; e Maxtec 2-in-1 muffled adapter to decrease
noise
flow rate [20]. Airway pressure and lung impedance
increase with increased gas flow as does end-expiratory
nasopharyngeal pressure [21, 22].
Due to the increased flow rate, HFNC may have the
added benefit of expediting washout of N2 from the lungs.
It has been shown that there is a linear positive correlation
between CO2 clearance and increase flow, with approxi-
mately 1.8 mL/s increase in CO2 clearance for every 1.0 L/
min increase in air flow [23, 24]. HFNC may increase N2
clearance in a similar way. HFNC also increases positive
pharyngeal pressure and may increase positive end-expi-
ratory pressure (PEEP). Studies have shown that end-
expiratory lung impedance increases end-expiratory lung
volume [24]. Fortunately, it has also been shown that
increasing PEEP likely has no deleterious effects on ICP
[25].
HFNC can provide higher FiO2 as manifested by a lar-
ger increase in PO2/FiO2 ratio in patients treated with
HFNC and provide the theoretical basis for using HFNC in
PNC because augmenting the PaO2 more effectively would
accelerate N2 washout [26–29]. Based in previous mathe-
matical model of the rate of pneumocephalus absorption,
HFNC can theoretically outperform other conventional
oxygen therapy devices such as NRB mask.
HFNC has become widely available, and it is a safe
modality. However, there are situations in which its
implementation may not be advisable, such as after surg-
eries compromising the integrity of the paranasal sinuses.
Noninvasive positive pressure ventilation has been reported
to actually cause PNC in patients with sinus trauma or
recent sinus surgery [30]. Though the concept of pul-
monary oxygen toxicity was been well described [31],
there are no reports of oxygen toxicity with use of HFNC.
Otherwise, there are no guidelines regarding contraindi-
cations of HFNC, but considerations should be taken as
with other modes of noninvasive positive pressure (de-
creased consciousness, claustrophobia, airway obstruction,
facial injury or malformation, copious sputum, high risk of
aspiration, unstable hemodynamics, and respiratory arrest)
[32].
Conclusion
Recognizing the limitations of a small case series, we
believe that these cases support as representative examples
for the introduction of HFNC when treating patients with
symptomatic PNC. In our first case, oxygen therapy with
HFNC was utilized because of unsatisfactory oxygen sat-
uration despite the use of a NRB mask and its application
led to rapid clinical and radiological improvement. In our
second case, HFNC was used, also followed by rapid
clinical and radiographic improvement. Our third case was
asymptomatic, but was treated empirically for radiographic
evidence on PNC, which resolved quickly with HFNC (at a
lower flow rate than the other two cases). These patients
were treated empirically for PNC in the context of their
recent surgeries, neurological decline, and intracranial air.
It is possible that the intracranial air was due to an unex-
panded postoperative brain, and that the changes in
neurological status could have been due to other causes
(such as seizures or spreading cortical depolarization).
Where in the first case, EEG was obtained negative, and in
all cases no other changes were made in management (all
patients were positioned at 30°, with bedrest, and minimal
sedation) because the symptoms were attributed to PNC.
The patients showed clinical improvement with the reso-
lution of the intracranial air after implementation of HFNC
oxygen therapy. While this temporal association could
have conceivably been coincidental, we think this is unli-
kely and the treating clinicians did not feel that additional
testing was necessary in any of the three cases. Also, we
found radiographic improvement faster than in other pub-
lished reports, supporting our proposed theory of
augmented air removal [5, 8, 13].
PNC remains a common complication of cranial trauma
and surgery, yet evidence to guide the most efficacious
mode of noninvasive oxygen therapy is sparse [33–36].
Current reported treatments are heterogeneous and vary
based on patient population, study design, duration of
treatment, modality of treatment, and target outcome. Most
studies focused on radiographic changes rather than
123

clinical improvement and more standardized studies are
required. By breathing 100% oxygen, a faster N2 washout
from the lungs occurs, facilitating the diffusion of the
nitrogen in the intracranial bubble into the circulating
blood following its gradient. The pronounced increase in
PaO2 achieved with HFNC (and perhaps the increased flow
rate) might accelerate PNC clearance in comparison with
the use of a NRB mask. In addition, since the air delivered
by high-flow nasal cannula is warmed and humidified, and
is delivered without a cumbersome mask, it is better tol-
erated by the patient. Consequently, we propose that HFNC
can represent a potentially useful strategy for the treatment
of symptomatic PNC.
Compliance with Ethical Standards
Conflict of interest Dr. Siegel reports no disclosures. Mrs. Hampton
reports no disclosures. Dr. Rabinstein reports no disclosures. Ms.
McLaughlin reports no disclosures. Dr. Diaz-Gomez reports no
disclosures.
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