Intradural endoscopic closure of dural breaches in a case of post-traumatic tension pneumocephalus

Post-traumatic tension pneumocephalus can become a life-threatening condition that urges the surgeon to repair the causal breach in the dura. Dural repair via craniotomy may be jeopardised by the fragility of the dura and by its firm adhesions to the bone, especially in aged patients. Transnasal sealing requires the opening of each of the paranasal sinuses or cells that line the frontal base.

We present the case of a 92-year-old man, in whom an alternative, minimally invasive procedure was chosen. The patient was in a poor general condition and suffered from progressive obtundation till coma, because of a massive tension pneumocephalus, which was not reversed by drainage of the intracranial air via a burr hole, but even increased instead. Through the existing burr hole at the coronal suture, a rigid endoscope was introduced. Because of a massive backward compression of the brain, the endoscope could be passed in front of it to visualize the dural defects at the level of the ethmoidal roof. Pericranium, harvested from around the burr hole, was glued against the defects. The procedure was repeated at the contralateral side.

After surgery, a gradual decrease of the amount of intracranial air was documented. The patient regained consciousness and was extubated. In spite of this favourable course, he suddenly died two weeks after surgery from combined pulmonary and renal dysfunction. Autopsy documented the efficacious endoscopic sealing of the skull base, which was the least invasive procedure in the given circumstances.