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Tension Pneumocranium, a Rare Complication of Transsphenoidal Pituitary Surgery: Mayo Clinic Experience 1976–1998

Division of Endocrinology, Metabolism and Nutrition, Internal Medicine (A.M.S., J.P.A., W.F.Y., T.B.N.), Division of Hypertension and Internal Medicine (W.F.Y.), Department of Neurosurgery (P.Y., M.J.E.), Mayo Clinic, Mayo Foundation, Rochester, Minnesota 55902

Address correspondence and requests for reprints to: William F. Young, Jr., MD, Division of Endocrinology, Metabolism, Nutrition and Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905.

Abstract

We describe four cases of symptomatic pneumocranium, a rare, potentially life-threatening complication of transsphenoidal pituitary surgery. Symptomatic pneumocranium manifested as impaired mental status, headaches, and grand mal seizures, early in the postoperative course after transsphenoidal pituitary surgery. Furthermore, a Cushing response, including systemic hypertension and bradycardia (secondary to intracranial hypertension) was seen, which has not been previously described in association with symptomatic pneumocranium. We describe a previously unreported risk factor for tension pneumocranium, untreated obstructive sleep apnea. Other factors predisposing to tension pneumocranium in our patients included: cerebrospinal fluid leaks, postoperative positive-pressure mask ventilation, large pituitary tumors, and intraoperative lumbar drainage catheters. Surgical drainage of the pneumocranium and repair of any coexistent cerebrospinal fluid leak markedly improved neurologic status.

Symptomatic pneumocranium occurring early in the postoperative course after transsphenoidal pituitary surgery is rare, but prompt recognition and treatment of this condition can be life-saving.