SESSION TYPE: Critical Care Student/Resident Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Pneumocephalus is the presence of air or gas within the cranial cavity. It is either idiopathic or is usually associated with disruption of the skull resulting from head and facial trauma, tumors of the skull base or after neurologic or otorhinolaryngologic surgery. We report a case of pneumocephalus secondary to a broncho-ventricular fistula.
CASE PRESENTATION: Our patient initially presented with an acute change in sensorium and generalized seizures. Computerized Tomography (CT) of the head at the time of admission revealed air within the cerebral sulci and superior sagittal sinus. Electrocardiogram demonstrated ST-segment elevation in leads V2-V3. An emergent echocardiogram showed air bubbles in transit through the left ventricle(LV). Chest CT indicated a fistula between the LV and lung parenchyma. Later, he developed tension pneumocephalus, was started on hyperbaric oxygen(HO) therapy, however his pneumocephalus kept worsening, he slipped into coma and subsequently died. Past medical history was significant for chest wall trauma followed by repair of the LV wall with Gore-Tex patch. Despite the repair he had multiple hospitalizations for recurrent hemoptysis.
DISCUSSION: Our patient suffered penetrating chest wall trauma approximately ten years prior, resulting in a fistula connecting the left ventricular cavity with the lung tissue causing recurrent hemoptysis. Ultimately, he developed air embolism, leading to tension pneumocephalus and finally death. Arterial gas embolism is a rare entity most commonly described in scuba divers, frequently with the presence of a patent foramen ovale (PFO). Emergent treatment includes administration of 100 % oxygen. HO should be considered early on in patients with pneumocephalus and delay in initiation of HO results in a sharp decrease in clinical efficacy after 4 to 5 hours[1-2]. Our patient had persistent accumulation of air bubbles despite hyperbaric chamber treatment, he developed rapid neurologic deterioration, coma, and ultimately death.
CONCLUSIONS: Persistent and significant hemoptysis in a patient who has undergone cardiopulmonary procedure should be carefully investigated for the possibility of a fistula formation. In extreme cases like this, seizures and other focal deficits should raise concern for the possibility of development of pneumocephalus. Additionally, emergent imaging with CT head, CT thorax, echocardiography coupled with bronchoscopy as emergent surgical intervention are warranted to prevent neurologic sequelae, morbidity, and mortality.
1) Leitch, DR, Green, RD. Pulmonary barotrauma in divers and the treatment of cerebral arterial gas embolism. Aviat Space Environ Med 1986; 57:931.
2) Murphy, BP, Harford, FJ, Cramer, FS. Cerebral air embolism resulting from invasive medical procedures. Ann Surg 1985; 201:242.
DISCLOSURE: The following authors have nothing to disclose: Amit Sharma, Namita Sharma, Amritpal Nat, Amit Dhamoon, Cristian Del Carpio
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