Presentation
Motor vehicle accident with progressive consciousness deterioration and severe right otorrhoea.
Patient Data
Non-contrast CT shows:
localised hyperdense swelling of the subcutaneous tissue at the right temporo-parieto-occipital region, indicating subgaleal haematoma
right temporal parenchymal contusion
a large amount of air is noted within the frontal and temporal subdural space bilaterally, compressing the frontal and temporal lobes and forming a peaking sign, and extending into the longitudinal fissure anteriorly, and separating the frontal lobes, resulting the so-called Mount Fuji sign
many air bubbles are noted within the subarachnoid space bilaterally, mainly in the Sylvian fissures, this is called air bubble sign
the air is noted within the lateral ventricles, the 3rd and 4th ventricles, forming an air-fluid level, representing pneumoventricle
the vertebral and basilar arteries are surrounded by air within the premedullary and prepontine cisterns
some air bubbles are noted within the spinal canal, which is known as pneumorrhachis
some air within the right parapharyngeal space is noted
Case Discussion
Skull fractures may may allow the air to get into the cranium, causing pneumocephalus, and in some cases, the air may enter the ventricles (pneumoventricle). Rarely, the gas exerts mass effects on the brain, and is then called tension pneumocephalus.
In this case, the brain is extremely compressed by tension pneumocephalus, and the intracranial pressure is severely elevated, and the cerebral perfusion pressure may decrease to the level of brain ischaemia, this requires immediate surgical treatment.
This patient underwent emergency surgery (frontal burr-holes were done bilaterally) to evacuate the air and to decompress the brain. Unfortunately, the patient did not do well after the surgery and suffered severe aspiration pneumonia and DKA, and he passed away 10 days later.
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