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Sequelae to Pneumoencephalography J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.36.1.146 on 1 February 1973. Downloaded from Journal ofNeurology, Neurosurgery, and Psychiatry, 1973, 36, 146-151 Sequelae to pneumoencephalography Y. S. WHITE, D. S. BELL, AND R. MELLICK From the Psychiatric Research Unit, Callan Park Hospital, Rozelle 2039, Australia SUMMARY Fifty patients were examined clinically and neurologically for seven days after pneumo- encephalography. Headache was present in 78%, neck stiffness in 3400, pyrexia in 38%, vomiting in 340/, tachycardia in 740/, a change in the level of consciousness in 18%, and abnormal neurological signs in 3000. Of the 13 patients with epilepsy, there was an increased frequency of seizures in four, associated with increased EEG epileptiform activity in three. EEG abnormality either appeared or increased in 7400 of cases on the second day after the air study. A mechanism for the production of these sequelae is proposed. It is concluded that these findings indicate that in most cases an organic brain syndrome follows pneumoencephalography. guest. Protected by copyright. Since its introduction in 1919, pneumoencephalo- METHODS graphy has been observed to produce a wide From a consecutive series of 54 patients undergoing range of side-effects: Bohn (1937), in a study of pneumoencephalography, the 50 to be described were 1,000 cases, reported headache, vomiting, py- followed for a minimum of seven days during which rexia, tachycardia, changes in blood pressure, time there was no other change in their management, stiffness in the neck, and mental confusion. four being omitted for the following reasons: two Changes in the constituents of cerebrospinal because of failed pneumoencephalograms, one Schwab and von because of unavoidable discharge on the day after fluid were reported by Storch pneumoencephalography, and one because of un- (1937), Levinson, Kaplan, and Cohn (1939), avoidable changes in medication in the post-pneumo- Wartenberg (1939), Robertson (1957), Marrack, encephalography period. The ages of the 50 patients Marks, and Couch (1961), Taveras and Wood ranged from 13 to 74 years; 29 were male and 21 (1964), and Dykes and Stevens (1970). Electro- female. All the patients were investigated at the encephalographic (EEG) abnormalities were Psychiatric Research Unit, which provides a neuro- found by Riehl and Ansel (1969) and Hammer logical and neurosurgical service to the psychiatric and Klingler (1969). Alterations in ventricular hospitals of New South Wales. size on radiological examination, present for Forty-four patients were cooperative enough to varying periods after pneumoencephalography, allow pneumoencephalography to be performed http://jnnp.bmj.com/ Robertson under neuroleptanalgesia; after premedication with were observed by (1947), Stallworthy sodium pentobarbitone 100-200 mg, droperidol and Savage (1955), Le May (1967), and Booker, 15-50 mg and fentanyl 75-200 ,tg were administered. Matthews, and Whitehurst (1969). Six patients were uncooperative or medically unwell These observations suggest that in many cases and for this reason were given a general anaesthetic, pneumoencephalography results in sequelae initiated with thiopentone sodium and relaxants and consistent with an organic brain syndrome. We continued after endotracheal intubation with nitrous In these cases the use the definition of the brain oxide/oxygen. latter premedication on September 27, 2021 by will organic syn- used was omnopon and scopolamine or pethidine drome proposed by Lipowski (1967)-that is, a hydrochloride and atropine. state of cerebral insufficiency in which there is The volume of air injected into the ventricles by a reduction in the level of cognition and a the lumbar route varied between 35 and 50 ml. In characteristic slowing of the EEG. Our study 28 cases a cerebrospinal fluid sample was obtained was designed to delineate the clinical features of before and after the injection of air and these samples the post-pneumoencephalography syndrome. were examined as soon as possible for protein, glu- 146 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.36.1.146 on 1 February 1973. Downloaded from Sequelae to pneumoencephalography 147 cose, chloride, and cells. In addition the cerebrospinal gested degenerative cerebellar disease and im- fluid was cultured and its Wassermann reaction proved after the air study, disappearing by the determined. As the results conformed with the seventh day of observation. cerebrospinal fluid changes that have already been In eight patients clouding of consciousness documented in the literature, a single analysis was made of each patient's combined specimens for the occurred or was aggravated after pneumo- rest of the series. encephalography. Confusion or incontinence The patients were kept in bed for three days and was present in four patients for one day and in were interviewed and examined daily for seven days another three confusion together with incontin- after pneumoencephalography. Particular attention ence for three to five days and one patient was paid to headache, nausea, vomiting, pain in the became drowsy. back, fever, level of consciousness, blood pressure, Three EEG records were obtained in each of41 pulse rate, and any changes in the pre-existent cases. In six cases only one record was obtained epilepsy. after the air study. In three either the pre- or post- An EEG was taken on the second and eighth day pneumoencephalography EEG was not done. In after the air study or as close as possible to these 34 cases an EEG abnormality either appeared or time intervals and a blind comparison made be- most tween these and the EEG performed before the pro- increased in the week after the air study. In cedure. During the observation period, changes in cases the abnormalities. were more marked on medication and any other procedure which could the second day and improved or resolved by the have affected the EEG were avoided. eighth. The changes consisted characteristically A lateral radiograph of the skull was taken every of a decrease of the order of 1-2 Hz in the fre- guest. Protected by copyright. day until the air bubble in the lateral ventricle was quency of the posterior dominant rhythm and less than 1 cm in width. A smaller air bubble could the appearance or increase to a moderate degree not be measured accurately. The period during of background slow wave activity in the theta which the air over the cortex could be demonstrated and delta range. Eight cases showed no change in the plain film was recorded. in the EEG and in five there appeared to be a decrease in the EEG abnormality. RESULTS Abnormalities with apparent localizing signifi- Headache lasting one to nine days occurred in 39 cance were misleading. In five a focal abnormal- of the 50 patients and vomiting for one to five ity appeared for the first time in the post- days in 17 patients. Nine patients had vomiting pneumoencephalography record, but in four of on the first day only and four of these had these the known cerebral pathology was diffuse omnopon and scopolamine as premedication for and generalized-for example, generalized cere- general anaesthesia. Neck stiffness was found on bral atrophy associated with senile dementia. A examination in 17 patients from the first to the seventh day. Pyrexia was recorded in 19 cases for one to two days, the maximum being 390 C. TABLE 1 One patient with pyrexia of 38° C for four days DURATION AIR DETECTED RADIOLOGICALLY http://jnnp.bmj.com/ was subsequently found to have a thrombosis in AFTER PNEUMOENCEPHALOGRAPHY the deep veins of one leg. A tachycardia of 90/min or greater occurred in 37 patients and Patients with Patients with normal air radiological diagnosis lasted one to four days. In all except three the studies of cerebral atrophy rate was greater than 100/min. Six patients were (n= 20) (n = 30) hypertensive for 1 to 12 hours after the air study Duration Cortical* Ventricular Cortical Ventricular and three became hypotensive during this period. (days) air filling air filling One of the latter had been given parenteral on September 27, 2021 by 1-2 11 3 9 1 chlorpromazine for sedation. In 15 cases, at 3-4 3 7 12 3 one 5-6 0 4 4 9 least of the following neurological signs 7-8 0 4 4 12 appeared in the period from the first to the 9-10 0 1 1 2 11-12 0 0 0 1 seventh day: unequal pupils, expressive dys- 13-14 0 1 0 2 phasia, pyramidal or extrapyramidal system involvement. Nystagmus in one patient sug- * Six patients did not have radiologically detectable air over the cortex. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.36.1.146 on 1 February 1973. Downloaded from 148 Y. S. White, D. S. Bell, and R. Mellick lateralized EEG abnormality appeared in two headache, neck stiffness, nausea and vomiting, cases, both with generalized cerebral pathology. pyrexia, tachycardia, alteration in the frequency On the other hand, the increase in bilateral EEG of fits, change in the level of consciousness, abnormality obscured the localizing sign in one appearance of neurological signs, and EEG case of temporal lobe epilepsy with a lateralized abnormalities. EEG abnormality. Headache was a common complaint. Robert- The five subjects whose EEGs improved son (1957) claimed that headache is rare after temporarily included a patient with focal pneumoencephalography. Taveras and Wood epilepsy whose focal discharge disappeared (1964) found that the absence of headache after during the week after the air study and a case of pneumoencephalography was related to the epilepsy in which the focal discharge and the presence of cerebral atrophy, but we were unable background slow wave abnormalities persisted to confirm this. unchanged, but the posterior dominant rhythm All patients with neck stiffness also had head- increased in frequency. ache and most of these did not notice any stiff- The pneumoencephalograms revealed that 20 ness.
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