Goran Latif Omer1,2
Riccardo Maurizi2*
Gianluca Velletrani2Beatrice Francavilla2Sahand S. Ali1Aland Salih Abdullah3
Stefano Di Girolamo2- 1Department of Clinical Sciences, University of Sulaimani-College of Medicine, Sulaymaniyah, Iraq
- 2Department of Otorhinolaryngology, University of Rome Tor Vergata, Rome, Italy
- 3Department of Basic Medical Sciences, University of Sulaimani-College of Medicine, Sulaymaniyah, Iraq
1 Introduction
We read with great interest the recent Article by Harlyjoy et al. (1) focusing on the management of traumatic tension pneumocephalus (TP) and the associated challenges in treating patients with head trauma in low- and middle-income countries (LMICs) (1). The authors' exploration into optimizing treatment protocols to reduce hospitalization times and minimize post-operative complications is both timely and pertinent. They notably underscore the critical need to address delays in the management of traumatic brain injuries by enhancing the utilization of health resources. We would like to provide our insights based on our experience in managing TP caused by post-traumatic ethmoidal damage, further contributing to this essential dialogue.
2 Discussion
While Pneumocephalus is a condition characterized by the presence of air in the intra cranial space caused by a breach in the cranium dural barrier, in TP air is progressively accumulated in the intra cranial space by a “ball valve” or “inverted pop bottle” mechanism. This mechanism categorizes TP as emergency condition due to the compressive effect of the trapped air on the brain. In the management of TP, the primary objective is the emergent decompression to alleviate intracranial pressure, combined with the repair of the causative defect (2). Endoscopic multilayer repair is the standard treatment for closing the craniodural breach. To achieve adequate intracranial decompression, the historical craniectomy has been replaced with the more recent craniotomy (3). Despite its efficacy, craniotomy is associated with a notable risk profile including soft tissue infection, extradural abscesses, subdural empyema, bone flap infection, and postoperative intracranial infection (4). Shi et al. (5) reported their experience with post craniotomy intracranial infection (PCII), showing a PCII rate of 6.8% among 5,732 patients.
Recent studies have explored various endoscopic techniques that simultaneously address the resolution of traumatic tension pneumocephalus (TP) and the closure of the bone defect responsible for cerebrospinal fluid leakage in a single surgical stage (6, 7). The development of new techniques and more angulated instruments for endoscopic surgery has increased the possibility of accessing more challenging endonasal areas (8). Single-step endonasal procedures may effectively treat both the TP and the craniodural defect concurrently, significantly lowering the risks of complications and shortening the duration of hospital stays. Patients treated with these strategies can expect reduced postoperative morbidity, quicker discharge, and a faster return to work. This is particularly relevant in LMICs, where the healthcare infrastructure may not support extensive postoperative care, and where the economic impact of prolonged hospitalization can be substantial.
To the best of our knowledge, the literature offers only four examples of TP resulting from post-traumatic ethmoidal roof damage, complicating the development of precise management guidelines. However, with equal effectiveness, the more appropriate direction should focus on procedures that allow a reduction in post-operative hospital stays and complications rate.
In conclusion, the adoption of endonasal endoscopic approaches for the first-line treatment of symptomatic TP due to post-traumatic ethmoidal defects offers a promising opportunity to improve patient outcomes not just in LMICs, but globally. This method underscores the potential of minimally invasive surgical techniques in TP management, promoting a model that prioritizes efficiency, safety, and accessibility while addressing the challenges of limited healthcare infrastructure and resources.
Author contributions
GLO: Writing – review & editing. RM: Writing – original draft, Writing – review & editing. GV: Writing – review & editing. BF: Writing – review & editing. SSA: Writing – review & editing. ASA: Writing – review & editing. SD: Writing – review & editing.
Funding
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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References
1. Harlyjoy A, Nathaniel M, Nugroho AW, Gunawan K. Traumatic tension pneumocephalus: a case report and perspective from Indonesia. Front Neurol. (2024) 15:1339521. doi: 10.3389/fneur.2024.1339521
2. Gâta A, Toader C, Trombitas VE, Ilyes A, Albu S. Endoscopic skull base repair strategy for CSF leaks associated with pneumocephalus. J Clin Med. (2020) 10:46. doi: 10.3390/jcm10010046
3. Dabdoub CB, Salas G, Silveira Edo N, Dabdoub CF. Review of the management of pneumocephalus. Surg Neurol Int. (2015) 6:155. doi: 10.4103/2152-7806.166195
4. Chughtai KA, Nemer OP, Kessler AT, Bhatt AA. Post-operative complications of craniotomy and craniectomy. Emerg Radiol. (2019) 26:99–107. doi: 10.1007/s10140-018-1647-2
5. Shi ZH, Xu M, Wang YZ, Luo XY, Chen GQ, Wang X, et al. Post-craniotomy intracranial infection in patients with brain tumors: a retrospective analysis of 5723 consecutive patients. Br J Neurosurg. (2017) 31:5–9. doi: 10.1080/02688697.2016.1253827
6. Latif Omer G, Maurizi R, Francavilla B, Rekawt Hama Rashid K, Velletrani G, Salah HM, et al. Transnasal endoscopic treatment of tension pneumocephalus caused by posttraumatic or iatrogenic ethmoidal damage. Case Rep Otolaryngol. (2023) 2023:2679788. doi: 10.1155/2023/2679788
7. Dalolio M, Cordier D, Al-Zahid S, Bennett WO, Prepageran N, Waran V, et al. The role of endonasal endoscopic skull base repair in posttraumatic tension pneumocephalus. J Craniofac Surg. (2022) 33:875–81. doi: 10.1097/SCS.0000000000008204
Keywords: tension pneumocephalus, endoscopic endonasal, head trauma, craniotomy, ethmoidal defect
Citation: Omer GL, Maurizi R, Velletrani G, Francavilla B, Ali SS, Abdullah AS and Di Girolamo S (2024) Traumatic tension pneumocephalus: a case report and perspective from Indonesia. Front. Neurol. 15:1391270. doi: 10.3389/fneur.2024.1391270
Received: 25 February 2024; Accepted: 18 April 2024;
Published: 03 May 2024.
Edited by:
Andrew P. Lavender, Federation University Australia, AustraliaReviewed by:
Givago Silva Souza, Federal University of Pará, BrazilCopyright © 2024 Omer, Maurizi, Velletrani, Francavilla, Ali, Abdullah and Di Girolamo. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Riccardo Maurizi, cmljY2FyZG9tYXVyaXppMTk5NCYjeDAwMDQwO2dtYWlsLmNvbQ==