WELCOME BACK TO ANOTHER CLINICAL IMAGE OF THE WEEK FROM THE CASE FILES OF THE BROWN EM RESIDENCY!

HPI: 48-year-old female with a history of seizures who presents to ED with confusion. The patient was found lying outside in her yard by her neighbors, confused and talking to herself. The patient is a poor historian and a reliable history is unable to be obtained.

ROS: Unable to be obtained

Vital signs: T: 98.2, HR: 82, BP: 107/64, R: 16, SpO2: 97% on room air

Pertinent Physical Exam: Patient is lying in bed comfortably. She is confused, but following commands. GCS 13 (E3V4M6). There is bruising noted on her tongue. She has left periorbital swelling, and ecchymosis to the right side of her face. Her mid face is stable. Her pupils are equal and reactive. Her TM’s are clear. Her neck is non-tender and supple. She has no obvious focal neurological deficits with appropriate strength and sensation appreciated in all four extremities.

Given the patient’s altered mental status, CT imaging of the brain was obtained:

What’s the diagnosis?

Or in layman's terms, air on the brain! This patient had a pretty remarkable amount of air that extended all the way to her mid-brain. CT face of the patient was also obtained given her facial trauma. There appeared to be bony defects in the roof of the left anterior ethmoid cells, indicative of a possible source of her pneumocephalus.

Discussion:

• Clinical suspicion for skull fracture should be heightened in the presence of depressed mental status, focal neurological deficits, scalp lacerations or contusions, bony step-offs on the skull, peri-orbital ecchymosis, headache, nausea and vomiting.
• Linear skull fractures typically have little to no clinical significance if imaging does not reveal any underlying brain injury, including intracranial hemorrhage. If asymptomatic, these patients can often be discharged after a period of observation.
• Depressed skull fractures place patients at risk for CNS infection, seizures, and death, with the vast majority of them being open fractures. They should receive prophylactic antibiotics (typically ceftriaxone and vancomycin), tetanus, seizure prophylaxis, and admitted to the hospital.
• Basilar skull fractures most typically involve the temporal bones. Specific signs of this fracture include peri-orbital and/or mastoid ecchymosis, CSF leak, and hemotympanum.
• CSF leak should be considered in the presence of clear ottorhea or rhinorrhea. If blood tinged, the “halo-sign”, a clear ring of fluid can be seen around a drop of blood. Laboratory testing for beta-2-transferrin (found exclusively in CSF fluid) can also be performed and are indicative of CSF leak.
• Most CSF leaks are treated conservatively, resolving spontaneously after a week.
• Traumatic pneumocephalus can be appreciated in the setting of a basilar or depressed skull fracture, or in any case in which the dura mater is compromised.
• Pneumocephalus is typically treated conservatively barring any significant complications, such as tension pneumocephalus. In one case series, tension pneumocephalus was treated with intracranial aspiration of air and the patients were given 100% oxygen to hasten air resorption.
• Another complication of pneumocephalus is meningitis, which was seen 68% of patients in one retrospective review of 284 cases of traumatic pneumocephalus. 
• The standard of care is to provide antibiotics in cases of pneumocephalus, although interestingly, a prospective, single-institution, randomized controlled trial of 109 patients examining prophylactic antibiotics (ceftriaxone) in traumatic pneumocephalus found no significant difference in the rates of meningitis.
• Outcome is generally favorable, with only a 10% mortality appreciated in one retrospective analysis of 21 patients, with “multiple air bubbles” being indicative of a worse prognosis.

Case Conclusion:

It was considered that the patient may have suffered from a seizure earlier on the day of presentation leading to the ethmoid sinus fracture and subsequently the pneumocephalus, or had developed pneumocephalus from prior head trauma, and then had a seizure as a result of this. ED treatment consisted of anti-epileptics, with a keppra load, prophylactic antibiotics for the ethmoid sinus fracture, and admission to the neurosurgical service where she was managed conservatively. No repair of the ethmoid sinus fracture was done due to the absence of CNS fluid leak.  Repeat imaging demonstrated improving pneumocephalus and her mental status eventually improved.

The contents of this case were deliberately altered to protect the identity of the patient. All content in this report are for educational purposes only. The patient consented to the use of these images.

Faculty Reviewer: Dr. Alyson McGregor

See you again soon!

References:

1: Rathore, AS, et. al. Post-Traumatic Tension Pneumocephalus: Series of Four Patients and Review of the Literature. Turkish Neurosurgery. January 1, 2016. 26 (2); 302-5.

2: Markham, JW. The Clinical Features of Pneumocephalus Based Upon a Survery of 284 Cases. Acta Neurochir. March, 1967; 16 (1). 1-78.

3: Eftekhar B, et. al. Prophylactic Administration of Ceftriaxone for the Prevention of Meningitis After Traumatic Pneumocephalus: Results of a Clinical Trial. Journal of Neurosurgery. November 1, 2004. 101 (5); 757-61.

4: Semih Keskil, et. al. Clinical Significance of Acute Traumatic Intracranial Pneumocephalus. Neurosurgery Review. 1998. 21. 10-13.

5: Heegaard, William, et al. Skull Fractures in Adults. UptoDate. <www.uptodate.com>. 2016.

6: Tintinalli, et. al. Emergency Medicine. 8th Edition. 2016. 1701.