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When and how did the air come in?

Published:March 21, 2021DOI:https://doi.org/10.1016/j.ejim.2021.03.005

      1. Case description

      An 84-year-old man with cognitive dysfunction was taken to the emergency room because of a change in consciousness. He came in with a Glasgow Coma Scale (GCS) score of E4V4M5. According to his family, this was not his usual state. It was difficult to hear the medical history from him, and there were few specific complaints. Upon physical examination, there were no abnormalities on the body surface and no complaints of pain. Head CT was performed to investigate the cause (Fig. 1 A and B).
      Fig 1
      Fig. 1A and B: Head computed tomography showing the air in the skull.
      C, D and E: Head computed tomography showing a fracture of the parietal bone (arrow).

      2. What is the diagnosis?

      Pneumocephalus.

      3. Discussion section

      Trauma is the most common cause of pneumocephalus as it accounts for approximately 70% of cases [
      • Pillai P
      • Sharma R
      • MacKenzie
      • et al.
      Traumatic tension pneumocephalus – Two cases and comprehensive review of literature.
      ]. Upon reviewing the CT, a fracture on the left side of the head was detected (Fig. 1 C, D and E). After that, a head examination was performed again, and although no clear trauma was observed, tenderness was noted at the fracture site. The most common symptom of pneumocephalus is headache, but it has reportedly occured in only 38% of cases. Meanwhile, changes in mental status have occurred in 44% of cases [
      • Markham JW.
      The clinical features of pneumocephalus based upon a survey of 284 cases with report of 11 additional cases.
      ]. Therefore, the testimony of people close to the patient is important. If the patient has dementia, it is often difficult to hear the patient's symptoms. In that case, it is important to ask the family if anything is different than usual. Head CT should not be hesitated if they say they are unusual. Although it is possible to diagnose pneumocephalus using plain images, CT examinations are more diagnostic. CT examinations can detect only 0.5 cm3 of air. In fact, the incidence of post-traumatic pneumocephalus is about 10 times higher on CT examinations than on plain images [
      • Zasler ND.
      Posttraumatic tension pneumocephalus.
      ]. In addition, when pneumocephalus is observed, the image should be reviewed for any signs of trauma.

      Conflict of Interest Statement

      I declare no conflicts of interest associated with this manuscript.

      References

        • Pillai P
        • Sharma R
        • MacKenzie
        • et al.
        Traumatic tension pneumocephalus – Two cases and comprehensive review of literature.
        Int J Crit Illn Inj Sci. 2017; 7: 58-64https://doi.org/10.4103/IJCIIS.IJCIIS_8_17
        • Markham JW.
        The clinical features of pneumocephalus based upon a survey of 284 cases with report of 11 additional cases.
        Acta Neurochir (Wien). 1967; 16: 1-78https://doi.org/10.1007/BF01401900
        • Zasler ND.
        Posttraumatic tension pneumocephalus.
        J Head Trauma Rehabil. 1999; 14: 81-84https://doi.org/10.1097/00001199-199902000-00009