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CC BY-NC-ND 4.0 · J Neurol Surg Rep 2024; 85(03): e138-e143
DOI: 10.1055/a-2376-7197
Case Report

Profound Pneumocephalus and Low-Pressure Hydrocephalus Triggered by Ventriculoperitoneal Shunt Placement after Resection, Fat Graft Reconstruction, and Radiotherapy for a Malignant Skull Base Schwannoma

Baylee Stevens
1   Departments of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States
,
Shannan Bialek
1   Departments of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States
,
Kyle Zhao
1   Departments of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States
,
Suhair Maqusi
2   Departments of Plastic Surgery, University of Oklahoma, Oklahoma City, Oklahoma, United States
,
Edward El Rassi
3   Departments of Otolaryngology-Head and Neck Surgery, University of Oklahoma, Oklahoma City, Oklahoma, United States
,
Jeremy Tan
4   Dean McGee Eye Institute, Oklahoma City, Oklahoma, United States
,
Christopher S. Graffeo
1   Departments of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States
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Abstract

Background Tension pneumocephalus is a rare postoperative complication, typically presenting with mental status changes or rapid neurological decline after craniotomy. We report a complex case of tension pneumocephalus triggered by graft retraction after ventriculoperitoneal (VP) shunt placement.

Case History A 39-year-old woman with a recurrent left trigeminal cavernous sinus schwannoma, status post one prior resection, two stereotactic radiosurgery treatments, and one course of fractionated radiotherapy, underwent radical resection with orbital exenteration and abdominal fat free graft reconstruction followed by adjuvant radiotherapy for malignant transformation. She developed subacute ventriculomegaly with altered mental status, prompting VP shunt placement. Three weeks later, she presented with profound pneumocephalus and intraventricular air originating from a large, left-sided sphenoid and maxillary defect, from which the fat graft had retracted. A right frontal external ventricular drain (EVD) was placed, resulting in immediate release of air under high pressure. Definitive treatment required skull base reconstruction with a latissimus dorsi free flap, contralateral nasoseptal flap, antibiotics, and VP shunt revision for treatment of combined cerebrospinal fluid (CSF) leak, pneumocephalus, ventriculitis, and low-pressure hydrocephalus. As of her last follow-up, she was restored to her initial postresection neurological baseline.

Conclusion Tension pneumocephalus is a rare and life-threatening emergency that requires immediate neurosurgical intervention. We report the index case of tension pneumocephalus induced by graft retraction following radiotherapy and CSF diversion. Where observed, tension pneumocephalus resulting from a skull base CSF leak may be associated with low-pressure hydrocephalus, and successful long-term management demands balancing the need for CSF diversion against the integrity of the skull base reconstruction.

Keywords

pneumocephalus - tension pneumocephalus - schwannoma - ventriculoperitoneal shunt - fat graft reconstruction - irradiation


Publication History

Received: 04 July 2024

Accepted: 25 July 2024

Accepted Manuscript online:
31 July 2024

Article published online:
30 August 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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