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Clinical and Radiological Characteristics of Traumatic Pneumocephalus After Traumatic Brain Injury

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Clinical and Radiological Characteristics of Traumatic Pneumocephalus After Traumatic Brain Injury Korean J Neurotrauma. 2020 Apr;16(1):49-59 https://doi.org/10.13004/kjnt.2020.16.e5 pISSN 2234-8999·eISSN 2288-2243 Clinical Article Clinical and Radiological Characteristics of Traumatic Pneumocephalus after Traumatic Brain Injury Ki Seong Eom Department of Neurosurgery, Wonkwang University School of Medicine, Iksan, Korea Received: Feb 22, 2020 ABSTRACT Revised: Mar 19, 2020 Accepted: Mar 19, 2020 Objective: Traumatic pneumocephalus (TP) is a common complication of traumatic brain Address for correspondence: injury (TBI), which is characterized by the abnormal entrapment of air in the intracranial Ki Seong Eom cavity after TBI to the meninges. The purpose of this study was to investigate the clinical and Department of Neurosurgery, Wonkwang University College of Medicine, 895 Muwang- radiological characteristics related to TP associated with TBI. ro, Iksan 54538, Korea. Methods: From January 2013 to March 2018, the data from 71 patients with TP after TBI were E-mail: [email protected] collected. Demographic and clinical characteristics were investigated and the distribution of TP was investigated as radiological characteristics. The author compared the demographic Copyright © 2020 Korean Neurotraumatology characteristics of TP to the data from the Korean Neurotrauma Data Bank System (KNTDBS). Society This is an Open Access article distributed Results: There was a higher ratio of males in patients with TP compared with KNTDBS. The under the terms of the Creative Commons mean age was 48.4±20.5 years and the incidence was highest in those 41–60 years of age Attribution Non-Commercial License (https:// (42.3%). Surgical treatment was performed in 23.9% patients. The mortality associated with creativecommons.org/licenses/by-nc/4.0/) the TP was 4.2%. The most common cause of injury was a traffic accident (52.1%). TP was which permits unrestricted non-commercial mainly located in the epidural space (53.5%) and showed a scatter pattern (60.6%). It was use, distribution, and reproduction in any medium, provided the original work is properly mostly located in the frontal and temporal area (81.7%). Skull fractures were observed in cited. 40.8% in the temporal bone and 25.4% in the frontal bone. Conclusion: The author identified epidemiology, clinical, and radiological characteristics of ORCID iDs TP associated with TBI. Although this study has many limitations, the author believes it is Ki Seong Eom https://orcid.org/0000-0002-8354-4024 worthwhile as it examines various characteristics of TP, which previously had relatively little clinical interest. Conflict of Interest The authors have no financial conflicts of Keywords: Traumatic pneumocephalus; Traumatic brain injury; Epidemiology interest. INTRODUCTION Intracranial air is known as an “aerocele” or “pneumocephalus” and it was initially described at autopsy by Chiari in 1884.1) Luckett10) first used the term “pneumocephalus” in 1913 when he reported the case of a man whose skull radiography showed air in the ventricles after a traffic accident (TA). The incidence of pneumocephalus depends on the etiology and can be seen in almost all cases of craniotomy. Pneumocephalus is mostly caused by trauma and the incidence of pneumocephalus after traumatic brain injuries (TBIs) varies from 1% to 82% depending on the series.7,18) https://kjnt.org 49 Traumatic Pneumocephalus after TBI Traumatic pneumocephalus (TP) is a common complication caused by TBI, which is characterized by the abnormal entrapment of air in the intracranial cavity after TBI to the meninges.9) Pneumocephalus can be sub-divided by location.13) Extra-axial locations include the epidural, subdural, and subarachnoid space, and intra-axial locations include parenchymal, intraventricular, and intravascular space. TP also present as a single lesion or multiple air bubbles scattered in several cisterns. In addition, it alone may occur after TBI and may be accompanied by intracranial lesions such as acute traumatic subarachnoid hemorrhage (TSAH), acute subdural hematoma (ASDH), acute epidural hematoma (AEDH), traumatic intracerebral hemorrhage (TICH), and traumatic intraventricular hemorrhage (TIVH). Conservative treatment alone is often sufficient for TP that occurs alone. Furthermore, the clinical significance of TP is often less than that of the accompanying traumatic intracranial lesions. For these reasons, TP has been often overlooked compared to other traumatic intracranial lesions, so there is not many clinical studies which consider TP. The purpose of this study was to investigate the clinical and radiological characteristics of TP after TBI. MATERIALS AND METHODS The study was approved by the Institute Ethical Committee of Wonkwang University Hospital (WKUH) and in compliance with institute's requirements. (WKUH 201908022). From January 2013 to March 2018, the author collected data from 71 patients with TP after TBI. Data were retrospectively reviewed from the medical and radiological records. All patients with TP confirmed by cranial computed tomography (CT) scan were included in the study. Exclusion criteria were pneumocephalus due to other non-traumatic reasons such as intracranial gas-forming bacterial infection, post-operative pneumocephalus, and fracture compound comminuted depressed (FCCD). In this study, the reason for the exclusion of pneumocephalus due to FCCD is that clinical and radiological findings have no significance because FCCD-induced pneumocephalus naturally occurs just below the head trauma site due to the compound depression of the skull. The author compared demographic characteristics of TP and data from the Korean Neurotrauma Data Bank System (KNTDBS) and statistically analyzed the characteristics. The Korean Society of Neurotraumatology recorded data from 2,617 patients with TBI from 20 institutions between September 2010 and March 2014 and provided various demographic data related to TBI in Korea though an established KNTDBS website.17) The author investigated the gender, age distribution, Glasgow coma scale (GCS), surgical treatment, and survival before comparing this study with various data from KNTDBS after obtaining permission from KNTDBS to analyze demographic characteristics. Other demographic and clinical characteristics of patients with TP, including cause of injury, leakage of cerebrospinal fluid (CSF), clinical manifestation (review of system) except headache, presence of scalp laceration, Glasgow outcome scale (GOS), and hospital stay, were investigated. The leakage of CSF was confirmed through otolaryngology consultation when patients complained of clinical symptom that the leak of clear and watery drainage from the nose and ear with a positional dependency. The outcome of TP was identified using the GOS at 6 months after TBI. Distribution of TP was investigated as radiological characteristics and the distribution was analyzed according to the location (epidural, subdural, intracerebral parenchyma, intraventricular, sella) (FIGURE 1A-E), side (left, right, bilateral, and midline), depth (superficial and deep) (FIGURE 1F & G), and brain area (frontal, temporal, parietal, occipital, and sella) of TP. Sites of skull fracture and intracranial traumatic lesions (none, TSAH, AEDH, ASDH, TICH, and TIVH) associated with TP on CT were also investigated (FIGURE 2). https://kjnt.org https://doi.org/10.13004/kjnt.2020.16.e5 50 Traumatic Pneumocephalus after TBI A B C D E F G H I FIGURE 1. Distribution of traumatic pneumocephalus according to location and depth. (A) Epidural, (B) subdural, (C) intracerebral parenchyma, (D) intraventricular, (E) sella area, (F) superficial, and (G) deep location. (H) Scatter and (I) concentrated pattern. https://kjnt.org https://doi.org/10.13004/kjnt.2020.16.e5 51 Traumatic Pneumocephalus after TBI A B C D E F FIGURE 2. Intracranial traumatic lesions associated with traumatic pneumocephalus. (A) None, (B) traumatic subarachnoid hemorrhage, (C) acute epidural hematoma, (D) acute subdural hematoma, (E) traumatic intracerebral hemorrhage, and (F) traumatic intraventricular hemorrhage. Statistical analyses SPSS version 22.0 (IBM SPSS Inc., Armonk, NY, USA) was used for statistical analyses. The Mann-Whitney U test was used for comparing non-categorical data. Differences were considered statistically significant if p-values were <0.05. RESULTS Demographic characteristics A total of 71 TBI patients with pneumocephalus were included in this study. The demographic characteristics of patients are summarized in TABLES 1 & 2. In order to determine the difference between TP and general TBI patients in relation to demographic characteristics, the data of the KNTDB which could be compared in this study were selected and analyzed. This is presented in TABLE 1. In this study, the proportion of male patients was 83.1%, and this proportion was higher in patients with TP compared with 70.8% of KNTDBS and this difference was statistically significant (p=0.025). The mean patient age was 48.4±20.5 years. https://kjnt.org https://doi.org/10.13004/kjnt.2020.16.e5 52 Traumatic Pneumocephalus after TBI TABLE 1. Demographic characteristics of patients with traumatic pneumocephalus comparable to KNTDBS Characteristics This study KNTDBS p-value Sex 0.025* Male 59 (83.1) 1,854 (70.8) Female 12 (16.9) 763 (29.2) Age (yr) 0.073 ≤20 9 (12.7) 292 (11.2) 21–40 11 (15.5) 422 (16.1) 41–60 30 (42.3) 834 (31.9) ≥61 21 (29.6) 1,069 (40.8) GCS 0.643 3–8 12 (16.9) 402 (15.3) 9–12 8 (11.3) 332 (12.7) 13–15 51 (71.8) 1,883 (72.0) Treatment 0.763 Surgical 17 (23.9) 668 (25.5) Nonsurgical 54 (76.1) 1,929
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