1317 - Clinically Significant Pneumocephalus Following Craniotomy for Vestibular Schwannoma Resection

This case describes a 67-year-old female with vestibular schwannoma (Koos grade IV) who presented with progressive headaches and hearing loss. Initial management included left frontal VP shunt placement for obstructive hydrocephalus, followed by right-sided retrosigmoid craniotomy for tumor resection. Her post-operative course was complicated by right cranial nerve VI and VII palsies, as well as exposure keratitis requiring tarsorrhaphy. Following a short course of acute rehabilitation, she was discharged, but returned within 2 weeks with persistent nausea, vomiting, and dizziness. Imaging revealed multifocal pneumocephalus and ventriculomegaly requiring endoscopic Eustachian tube ablation. During her subsequent rehabilitation admission, her course was complicated by somnolence and worsening hydrocephalus, managed by shunt valve adjustment.

Discussions:

Pneumocephalus is a common radiographic finding after posterior fossa surgery, but clinically significant or tension pneumocephalus is rare, occurring in a small percentage of cases. One known risk factor for this complication is the presence of a VP shunt, which causes negative pressure in the presence of surgical osteodural defects that facilitate air entry and entrapment. Retrosigmoid approaches for vestibular schwannoma resection are associated with pneumocephalus, particularly in large tumors and those with preoperative hydrocephalus. Most cases are self-limited, but symptomatic pneumocephalus can be life-threatening and may present after initial postoperative imaging. Most readmissions for post-operative craniotomy-related complications are within the first two weeks post-discharge.

Conclusions:

This case highlights the potential value of individualized surveillance imaging before discharge from inpatient rehabilitation in patients at elevated risk for post-craniotomy pneumocephalus and related complications. Targeted imaging in high-risk patients, such as those with pre-existing VP shunts, may facilitate early detection and prevention of morbidity and readmission.