INTRODUCTION: Pneumocephalus from a subarachnoid-pleural fistula following resection of a pulmonary neoplasm is a rare postoperative occurrence. It is usually described in literature following open or closed spinal cord injury and is less frequent following a thoracic surgery.
CASE PRESENTATION: This is a case of a 72-year-old gentleman who underwent pneumonectomy in April 2005 for a recurrent bronchogenic carcinoma treated two years prior by left lobectomy and rib resection. Findings on resection included an extremely thick and partly calcified fibrotic pleura at the site of rib resection and a lesion in the left lower lobe bronchial stump adjacent to the aorta, which revealed a squamous cell carcinoma. No pleural-subarachnoid fistula was noted intra-operatively. After an uneventful post-surgical course the patient was discharged but readmitted for recurrent falls. The patient's blood pressure was 122/88, pulse 90, respirations 18, and a temperature of 98°F. There was no indication of infection on spinal fluid analysis. On neurological exam patient was lethargic and Glasgow coma score was 13 (15 prior to surgery). Cranial nerves were intact except for flattened right nasolabial fold. The right arm had 3/5 motor strength and cerebellar function could not be assessed. CT scan of the head revealed a pneumocephalus that, after conservative management, resolved spontaneously.
DISCUSSIONS: We present a new case of subarachnoid-pleural fistula leading to a pneumocephalus following pulmonary neoplasm resection that responded to conservative management. Bronchogenic carcinoma requiring rib resection exposed the patient to risk of a dural tear. Postoperative pneumocephalus usually presents in 1 to 8 weeks. Findings include headache and altered mental status. In this case, the patient returned with symptoms within 7 days. Myelography followed by CT is the definitive test for diagnosing fistulae and treatment depends on the neurological status of the patient. At times lumbar drainage and surgical repair of the fistula may be required, however cases frequently resolve spontaneously such as ours. Antibiotics may be used to prevent infection. If a tension pneumocephalus is present with neurological effects, the fistula should be drained. In addition to a thoracotomy or thoracoplasty, and depending on the location of the subdural effusion, the repair can also be through a posterior-laminectomy and placement of an intradural or extradural-patch.
CONCLUSION: Pneumocephalus following a thoracotomy is rare. However, as demonstrated in this case, care should be taken during tumor resection to prevent damage to the dural sleeve. Any patient presenting with neurological deficits following thoracic surgery should be assessed for the possibility of this entity.
DISCLOSURE: Joseph Ng, No Financial Disclosure Information; No Product/Research Disclosure Information