Iatrogenic tension pneumocephalus and Durets hemorrhage

Case contributed by Dr Victor Tang


A 46-year-old man with a background of Huntington’s Disease presented to a regional hospital with a two-week history of general decline and increasing falls. On initial presentation patient was GCS10, with CT Brain showing bilateral subdural haematomas. The patient was subsequently transferred urgently to a tertiary hospital. On arrival he was GCS7 with fixed and dilated pupils. Bilateral burr holes evacuated 300mls of haematoma. The below CT Head series was acquired 1 hour post burr hole surgery.

Patient Data

Age: 46
Gender: Male

Bilateral frontal and parietal burr holes.

Bilateral tension pneumocephalus causing frontal and parietal lobe compression, with 7mm midline shift to the right.

Ischemia in both occipital lobes extending into the posterior temporal lobes, consistent with bilateral PCA territory infarcts.

Bilateral basal ganglia infarcts.

Midline brainstem hemorrhage.

Nil cerebellar herniation.

Case Discussion

The above CT series demonstrates two classical signs:

  1. The Mount Fuji sign of tension pneumocephalus.

  2. The classical appearance of Duret hemorrhage, with hemorrhage of the brainstem in the midline.

Tension pneumocephalus is a known but rare complication of subdural hematoma evacuation.  Air enters through the dural defect but is unable to escape, often known as a “ball-valve” mechanism. The subsequent increase in intracranial pressure produces a mass effect on the frontal and parietal lobes.

Additionally, this case illustrates the sequelae of tension pneumocephalus. The raised supratentorial pressure has resulted in caudal shift of the brainstem, with the associated injury to the basilar artery resulting in the Duret hemorrhage. Ischemia of the branches of the basilar artery would account for the PCA territory infarcts.

Acknowledgement is made to Dr David Preston who initially reported the film.

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Case information

rID: 57823
Published: 15th Jan 2018
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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