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Aphasia and Upper Limb Weakness Reversed by Reabsorption of Pneumocephalus

Tasneem H. Mehesry, Nissar Shaikh, Duthie DJR, Malmstrom MF, Marcus AE, Adnan Khan

Background: Air in the cranial vault or pneumocephalus is a recognised complication following evacuation of chronic subdural hematoma through a burr hole. Air that develops a tension pneumocephalus has a spaceoccupying effect causing pressure to surrounding structures. We report a case of aphasia and upper limb weakness that followed the onset of tension pneumocephalus, and resolved when the pneumocephalus resolved. Case: A 68 year old right-handed male patient attended hospital after a fall one month previously. He had headache, a limp, and recent onset right-sided upper limb weakness, with power of 4/5. Computerised tomography (CT) scan showed bilateral sub-acute subdural hematoma larger on the left, with significant midline shift.The haematomas were evacuated through four burr-holes. Drains were brought to the exterior from over both parietal regions and from an intra-cerebral ventricle. The patient was extubated immediately after surgery and breathed spontaneously. He had increased weakness in his right arm, with power 1/5, and expressive aphasia, but was obeying commands. Drains were confirmed patent. A CT scan was performed immediately. This showed bilateral parietal, and left sided frontal tension pneumocephalus with no hematoma. There was no ischemia on magnetic resonance imaging (MRI). He was laid supine and given oxygen 100% to breathe. Within six hours his arm weakness improved to power of 5/5 and he resumed talking. Conclusion: Pneumocephalus may occur after burr hole drainage of a haematoma despite placing drains. In this case, a new neurological deficit with the head elevated prompted CT scan that diagnosed tension penumocephalus. Drains remained patent; so the patient was laid supine and given oxygen 100% to breathe, after which function returned. Tension pneumocephalus should considered as a reversible cause of deterioration after burr hole evacuation of subdural haematomas