ARTICLE IN PRESS doi:10.1510/icvts.2008.198028
Interactive CardioVascular and Thoracic Surgery 8 (2009) 680–681 www.icvts.org
Case report - Thoracic oncologic
Tension pneumocephalus complicating Pancoast tumor resection Nikolaos Barbetakis*, Georgios Samanidis, Dimitrios Paliouras, Christodoulos Tsilikas Department of Thoracic Surgery, Theagenio Cancer Hospital, A. Simeonidi 2, Thessaloniki, 54007, Greece Received 10 November 2008; received in revised form 27 December 2008; accepted 30 December 2008
Abstract A case of tension pneumocephalus following Pancoast tumor resection is presented. Conservative management was successful. The presenting symptoms and signs, diagnostic methods and options for treatment are discussed and reviewed. 䊚 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Pneumocephalus; Pancoast tumor
1. Introduction Pneumocephalus is a rare complication that has most often been described as a result of skull-based fractures or intracranial operations. Such a complication is very rarely seen after thoracotomy with 20 cases reported to date in the international literature. A case of tension pneumocephalus following thoracotomy for Pancoast tumor is presented. Conservative management with head low position and discontinuation of chest tube suction proved to be successful. 2. Case report A 52-year-old man was admitted with no relevant medical history and a 30-day history of pain in the right shoulder and scapula radiating from the brachial plexus. Symptoms and radiographs were consistent with Pancoast tumor without mediastinal lymph node involvement. Tissue obtained by fine needle aspiration of the lesion was positive for squamous cell lung carcinoma. There was no evidence of metastatic disease. The patient underwent preoperative radiotherapy (3000cGy – 10 sessions) followed by surgery. The tumor was approached through a high posterolateral incision (Shaw Paulson approach). A right upper lobectomy with en-bloc resection of the second, third and fourth ribs and mediastinal lymph node dissection were performed. The proximal rib resections were performed at the costovertebral joints and the neurovascular bundles were individually ligated between vascular clips. There were no difficulties encountered during surgery and no cerebrospinal fluid leakage was noted and the patient was extubated in the operating room. On the 3rd postoperative day, the patient developed headache and sudden alteration in mental status with decreased level of consciousness. At this stage, the patient *Corresponding author. Tel.: q302310898304; fax: q302310845514. E-mail address:
[email protected] (N. Barbetakis). 䊚 2009 Published by European Association for Cardio-Thoracic Surgery
was being nursed in upright sitting position in the bed. He was readmitted to the intensive care unit and computed tomography scan of the head revealed gaseous distention of ventricles of the brain without evidence of midline shift or herniation (Fig. 1). The diagnosis of subarachnoid-pleural fistula was suspected. The patient was placed in head low position and chest tube suction was discontinuated as it could exacerbate cerebrospinal fluid extravasation. Subsequently, there was improvement in the mental status and the patient gradually recovered completely from his symptoms within 48 h. The chest drains were removed on postoperative day 12 when the drainage was minimal and air leak was stopped. A repeat computed tomographic scan revealed resolution of a large amount of air in the ventricles (Fig. 2). Ten months later the patient was asymptomatic without pneumocephalus in the follow-up. 3. Discussion Surgery of Pancoast tumors can result in complications and sequelae depending on what structures have been invaded. The tumor must be resected en bloc when ribs and transverse processes are involved with a risk of tearing the dura mater and the nerve roots. This is very likely to happen when the costovertebral angle is involved in the neoplastic process. The combination of an air leak and pneumothorax along with a dural injury can result in pneumocephalus. However, pneumocephalus has also been reported as a complication of routine thoracotomy and epidural anesthesia w1x. The most commonly accepted explanation of this complication in the postoperative period, is the traction and avulsion of dorsal nerve root. In our case, nerve roots were avulsed during extrapleural dissection where the tumor was adherent. It is unlikely that epidural anesthesia was related to this complication as it was obvious that the large amount of air in the ventricles could not have entered from the epidural puncture site. Including this case, only 20 cases of cerebrospinal fluid
ARTICLE IN PRESS N. Barbetakis et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) 680–681
Fig. 1. Axial computed tomographic scan of the brain showing air in the ventricles and subarachnoid space.
Fig. 2. A repeat computed tomographic scan, ten days later, revealed resolution of the large amount of air in the ventricles.
subarachnoid-pleural fistula associated with pneumocephalus following Pancoast tumor resection have been described in the literature w2x. Ten cases, our case included, received preoperative radiotherapy. The presenting symptoms of pneumocephalus vary widely, but headache is almost always present. Initial pneumocephalus symptoms appear between the first days and eight weeks after surgery and are characterized by headache, altered mental status and occasionallly reduced states of consciousness. In addition, patients may present with nausea, vomiting, dizziness, stiff neck, aphasia or hemiplegia w3x. Symptoms of typical pleural effusion may appear if drainage tubes have been removed. In our case headache, with sudden alteration in mental status and pneumocephalus in the computed tomography established the diagnosis of a subarachnoid-pleural fistula. Other tests used to confirm the presence of the fistula are based on a pleural fluid analysis characterized by clear transudate, few cells, normal glucose and low protein levels or the measurement
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of central nervous system specific ferritin. However, pleural fluid analyses can produce false negatives w4x. Myelography followed by computed tomography has been found to have better spacial resolution than isotope imaging and has become the definitive test for diagnosing and locating fistula w5x. The treatment of pneumocephalus depends on either obliteration of the spinal fluid leak or the resolution of pneumothorax. The presence of pneumothorax, the size of fistulous tract and the time interval from thoracotomy to the onset of symptoms affect the treatment choices. When a subarachnoid-pleural fistula is recognized during thoracotomy, it should be repaired by suture ligation or occlusion with a vascularized muscle pedicle. In addition, surgical sealants may be used, although use in large volumes could lead to brain stem or spinal cord compression w6x. Before chest closure, during Pancoast tumor resections, patients are routinely ventilated with increased intrathoracic pressure, which increase spinal fluid pressure and may identify a spinal fluid fistula w7x. International literature suggests that acute subarachnoidpleural fistula can occasionallly be managed conservatively with bed rest, flat-head position and removal of chest tube suction. Others support that their patients recovered completely after head low position and suction on chest drains w1x. Failure to respond to conservative measures requires surgical procedure. Various surgical strategies have been used, including laminectomy and repair with a patch placement or thoracoplasty with proximal nerve root ligation w8x. In no case reviewed direct intracranial intervention was required. In our case, conservative management with head low position and discontinuation of chest tube suction proved to be successful. As a conclusion, prevention or intra-operative recognition and prompt repair should be the mainstay of treatment for this complication. Conservative management should be considered initially. References w1x Reddy HV, Queen S, Prakash D, Jilaihawi AN. Tension pneumocephalus: an unusual complication after lung resection. Eur J Cardiothorac Surg 2003;24:171–173. w2x Ladehoff M, Zachow D, Koch C, Nowak G, Echelmeyer A, Arnold H, Giese A. Cerebral hemorrhage and tension pneumocephalus after resection of a Pancoast tumor. Acta Neurochir 2005;147:561–564. w3x Brown MW, Symbas P. Pneumocephalus complicating routine thoracotomy: symptoms, diagnosis and management. Ann Thorac Surg 1995;59: 234–236. w4x Lloyd C, Sahn SA. Subarachnoid pleural fistula due to penetrating trauma. Case report and review of the literature. Chest 2002;122:2252– 2256. w5x Heller JG, Kim HS, Karlson GW. Subarachnoid-pleural fistula. Management with a transdiaphragmatic pedicled greater omental flap. Report of two cases. Spine 2001;26:1809–1813. w6x Short HD. Paraplegia associated with the use of oxidized cellulose in posterolateral thoracotomy incisions. Ann Thorac Surg 1990;50:288– 290. w7x Bilsky M, Downey R, Kaplitt M, Elowitz E, Rusch V. Tension pneumocephalus resulting from iatrogenic subarachnoid-pleural fistulae: report of three cases. Ann Thorac Surg 2001;71:455–457. w8x Da Silva VF, Shamji FM, Reid RH, Carpio-O’Donovan R. Subarachnoidpleural fistula complicating thoracotomy: a case report and review of the literature. Neurosurgery 1987;20:802–805.
