Posttraumatic delayed subdural tension pneumocephalus
A 75-year-old right-handed male with trauma signs on his head (right-sided paraorbital hematoma and a wound in his frontal region) was admitted to Yalta City Hospital after he fell down at the entrance of his house. He lost consciousness for about 2 minutes. On admission, he was Glasgow coma scale (GCS) 15 with right-sided exophthalmos up to 4 mm. He complained of headache and diplopia while looking to the right.\nNeurologically: Limitation of the right eye abduction, eyeballs weak of convergence.\nCT showed frontal sinus fracture with extension to the right orbital roof and minimal pneumocephalus []. A wound with fracture of frontal sinus outer wall in its depth was closed with sutures. Next day, nasal liquorrhea occurred.\nOn the fifth day after admission to neurosurgical department, he was noticed to be deteriorating neurologically. His GCS dropped to 12, meningeal signs were found and he became bradyapneic. It was a “Mount Fuji sign” on the cranial CT scans [].\nUnder general anesthesia, a burr-hole was placed in the right frontal region and subdural space was irrigated with normal saline and admitted to the intensive care unit (ICU).\nNext day after the surgical treatment, he improved and became awake. He was successfully weaned of the ventilator and admitted to the neurosurgical department. Subdural drain was removed.\nOn the brain CT scans there was a minimal residual air []. Liquorrhea stopped.\nPatient underwent a conservative treatment and observation. On the sixth day after the operation, an episode of hyperthermia up to 38°C developed.\nOn the 11th day, nasal liquorrhea resumed. On the background of the therapy, a sustained clinical improvement was achieved.\nPatient refused to undergo proposed surgical intervention, aimed at dura defect closure in the posterior wall of the frontal sinus. On the 22nd day after hospitalization, on the urge of family members, patient was transferred to Kyiv Municipal Clinical Emergency Hospital. On the second day after transfer, nasal liquorrhea resumed. Watertight dura closure and cranioplasty was performed. The postoperative period was uneventful and CSF was without signs of inflammation. In 12 days after surgery, patient was discharged. At his 14 month follow-up, he has no neurological deficit and no signs of liquorrhea and meningitis.