Tension pneumocephalus following craniofacial resection

The craniofacial approach is a reliable method for excising tumors involving the anterior skull base. Advances in technique have minimized complications. Although cerebrospinal fluid leaks and meningitis are well-known complications, tension pneumocephalus is not well described. We review two cases and discuss the pathophysiology, clinical manifestations, radiographic features, and treatment of tension pneumocephalus.

Case study. We reviewed the records of all patients who underwent anterior craniofacial resection at our institution, a tertiary care center, from 1976 to 1993. Among 45 patients identified, 2 had tension pneumocephalus.

Neurologic deterioration after anterior craniofacial resection occurred in both patients in the immediate postoperative period. Both patients had extradural intracranial air under pressure and were diagnosed with tension pneumocephalus. In one patient, this was treated by needle aspiration followed by catheter drainage, and the second patient was treated with needle aspiration followed by airway diversion. The first patient recovered fully and was discharged on postoperative day 14; the second patient's mental status did not return to the preoperative level, and he was discharged on postoperative day 23 to a rehabilitative facility. Approximately 3 months later, his level of mentation returned to baseline.

Tension pneumocephalus is a potentially devastating complication that may occur after craniofacial resection. It requires prompt recognition and treatment to minimize morbidity.