Patient presented for elective left orbital exenteration and flap repair in the context of left medial canthus squamous cell carcinoma. He was found to be difficult to rouse post-anaesthetic. A non-contrast CT brain was performed post-operatively.
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A non-constrast CT brain demonstrated extensive subdural air causing a mass effect on the underlying brain parenchyma consistent with a tension pneumocephaly. The imaging sign featured here is the Mount Fuji sign which involves separation of the frontal lobes simulating the appearance of a silhouette of Mount Fuji. Another sign of pneumocephalus demonstrated here is the air bubble sign which reflects small collections of air within the subarachnoid space.
Urgent neurosurgical intervention with decompression was performed and the patient made a good recovery. This is an example of a rare surgical complication of orbital exenteration. The mechanism was likely due to a ball-valve effect causing a one-way communication of air via the surgical flap into the dural space.