Visual Diagnosis in Emergency Medicine| Volume 57, ISSUE 4, e125-e126, October 2019

Profound Pneumocephalus in an Infant

      A 4-month-old boy with history of communicating hydrocephalus, who was 5 days postoperative from a parieto-occipital ventriculoperitoneal (VP) shunt placement, presented to the emergency department with fussiness and clear drainage from the postoperative incision. The patient was afebrile, mildly tachycardic for age, awake, fussy, and difficult to console. His physical examination revealed a markedly sunken anterior fontanelle and a 5 cm × 1 cm × 2 cm area of fluctuance underlying the parietal incision. Clear fluid was observed leaking from the suture line. A shunt series demonstrated marked intraventricular pneumocephalus (Figure 1), presumably due to a ball valve effect of the leaking shunt, causing it to backfill with air. During neurosurgical repair, the patient was noted to have a pseudomeningocele formation (a pseudomeningocele is an extradural collection of cerebrospinal fluid that results from a dural or arachnoid tear; it is an uncommon complication of spinal surgery). The patient was admitted and underwent prompt neurosurgical revision, including shunt externalization and dural repair. His postoperative course was complicated by a brief episode of meningitis based sepsis. After clinical stabilization, he underwent placement of a revised VP shunt without complication and was subsequently discharged home on the second postoperative day.
      Figure thumbnail gr1
      Figure 1Shunt series images demonstrate profound intraventricular pneumocephalus at arrows.
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