Gore PA, Maan H, Chang S, et al. Normobaric oxygen therapy strategies in the treatment of postcraniotomy pneumocephalus

Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ 85013, USA.
Journal of Neurosurgery (Impact Factor: 3.74). 06/2008; 108(5):926-9. DOI: 10.3171/JNS/2008/108/5/0926
Source: PubMed


Postsurgical pneumocephalus is an unavoidable sequela of craniotomy. Sufficiently large volumes of intracranial air can cause headaches, lethargy, and neurological deficits. Supplemental O(2) to increase the rate of absorption of intracranial air is a common but unsubstantiated neurosurgical practice. To the authors' knowledge, this is the first prospective study to examine the efficacy of this therapy and its effect on the rate of pneumocephalus absorption.
Thirteen patients with postoperative pneumocephalus that was estimated to be > or = 30 ml were alternately assigned to breathe 100% O(2) using a nonrebreather mask (treatment group) or to breathe room air (control group) for 24 hours. Head computed tomography (CT) scans without contrast enhancement were obtained at the beginning and end of treatment or control therapy. A neuroradiologist blinded to the type of treatment used software to calculate the 3D volume of the pneumocephalus from the CT scans. The percentage of pneumocephalus absorption was calculated for each study participant.
There was no statistically significant difference between the treatment and control groups regarding the mean initial pneumocephalus volume or time interval between CT scans. There was a significant difference (p = 0.009) between the mean rate of pneumocephalus volume reduction in the treatment (65%) and control groups (31%) per 24 hours. No patient suffered adverse effects related to treatment.
Administration of postsurgical supplemental O(2) through a nonrebreather mask significantly increases the absorption rate of postcraniotomy pneumocephalus as compared with breathing room air.

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    • "Treatment of pneumocephalus in our institution involves continuous supplemental 100% oxygen by a nonrebreather mask. The increased oxygen tension in the bloodstream has previously been shown to more rapidly clear the volume of pneumocephalus in case reports and small studies [14, 15]. However, increasing the inspired oxygen beyond 40% may only provide marginal increases in the rate of absorption [14]. "
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    ABSTRACT: Symptomatic pneumocephalus is a rare complication of degenerative lumbar spine surgery. This is a case report of a patient who developed transient diplopia associated with pneumocephalus following lumbar spine surgery complicated by a dural tear. The diplopia improved as the pneumocephalus resolved. Factors involved in the development of pneumocephalus include an unintended durotomy and intraoperative reverse Trendelenburg positioning that was utilized to decrease the risk of postoperative vision loss. When encountering cerebrospinal fluid (CSF) leakage intraoperatively, spine surgeons should level the operating table until closure of the dural defect to prevent potential complications associated with pneumocephalus. If postoperative patients complain of severe headaches or display a focal cranial neurologic deficit, then a computed tomography (CT) scan of the brain should be ordered and evaluated. Consulting neurologists should be aware of the circumstances surrounding this rare complication.
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    • "These include; endolumbar infusion of isotonic saline, ringer's solution or air during surgery, hyperhydratation of the patient, trendelenburg positioning of the patient with lowering of the head 30° horizontally and bed rest for up to a week, the replacement of the hematoma with carbon dioxide gas or oxygen, craniotomy without closure of the dura or replacing the bone plate, or an implant of a subcutaneous reservoir with a catheter introduced into the subdural cavity.[171826–31] The treatment of pneumocephalus with supplemental breathing of 100% O2 had been demonstrated to be effective.[4632] "
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    • "Additional therapeutic recommendations include laxative use to decrease intra-abdominal pressure during bowel movements and supplemental oxygen therapy to hasten the absorption of pneumocephalus (vs. air).16 Although clinicians have prescribed hyperbaric oxygen therapy (HBO) for treating pneumocephalus, there is currently no literature on HBO efficacy. "
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