Tension pneumocephalus in a patient with a scalp wound and ventriculo-peritoneal shunt: case report and literature review

Skull defects and even meningeal defects are responsible for the majority of pneumocephalus cases. Sometimes, several factors can produce intracranial gas under pressure (tension pneumocephalus) with severe neurological impairment. We present a case of a 66 year old woman with a double ventriculo-peritoneal shunt that was admitted to the emergency service with an intracranial hypertension syndrome. A scalp wound was found on the physical examination and a brain CT showed a tension pneumocephalus. The scalp wound was just located on the border of a cranioplasty made after surgical removal of a parasagital meningioma eight years ago. Evacuation of pneumocephalus, reparation of cranial and meningeal defects and modification of factors contributing to the tension pneumocephalus (ventricular-peritoneal shunts programmed to low pressure) were performed. When we found a patient with a tension pneumocephalus we must think not only about a skull or meningeal defect but also look for other elements that produce gas inside skull under pressure (shunts, cerebrospinal fluid leak between others). Therefore, therapeutic approach has three parts: pneumocephalus drainage, to find and repair entrance of gas and to modify factors that turn pneumocephalus in a tension pneumocephalus.