Management of Pneumocephalus and Related Conditions

Diagnosis and Assessment

• The American Society of Neuroimaging recommends obtaining CT imaging to confirm diagnosis and differentiate from other conditions, such as pneumomediastinum, and assessing for signs of tension pneumocephalus (Mount Fuji sign on CT) 1
• CT scanning is recommended for differentiating pneumomediastinum from complex bullous lung disease, suspected esophageal perforation, or when plain chest radiograph is obscured by surgical emphysema, as suggested by the British Thoracic Society 2

Treatment and Management

• The American Academy of Neurology suggests avoiding high-flow nasal oxygen in patients with base of skull fractures, as it may worsen pneumocephalus 1
• Supplemental high-flow oxygen (10 L/min) is recommended by the American Thoracic Society to increase the rate of air reabsorption in patients with pneumomediastinum 2
• Rest and activity limitation, adequate analgesia for pain control, and avoiding maneuvers that increase intrathoracic pressure (Valsalva, forceful coughing) are recommended by the European Society of Anaesthesiology for patients with pneumomediastinum 2

Prevention of Complications

• The American College of Surgeons recommends urgent neurosurgical consultation for decompression, and may require burr hole placement or craniotomy to relieve pressure, in cases of tension pneumocephalus 1
• For patients who develop a large or symptomatic pneumothorax, consideration should be given to aspiration or chest tube placement according to pneumothorax guidelines, and never clamp a bubbling chest tube, as recommended by the British Thoracic Society 2
• Patients with underlying lung disease may require more aggressive monitoring and management, and consideration of admission to a unit with respiratory expertise, as suggested by the European Respiratory Society 3

Patient Care and Monitoring

• The American Heart Association recommends monitoring vital signs, neurological status, and oxygen saturation, and watching for warning signs of deterioration, such as increasing headache, altered mental status, and seizures 1
• Monitoring during hospitalization should include respiratory rate, oxygen saturation, heart rate, and blood pressure, and watching for warning signs of deterioration: increasing dyspnea, expanding subcutaneous emphysema, hemodynamic instability, as recommended by the Anaesthesia society 4

Discharge Criteria

• The American Academy of Neurology suggests that resolution or significant improvement of symptoms, no respiratory distress, stable vital signs and neurological status, and follow-up imaging showing resolution or significant improvement of pneumocephalus are indicators for discharge 1
• Observation for 1-2 days is recommended for patients with mild and improving symptoms, and longer hospitalization may be needed for patients with significant symptoms or underlying conditions, with discharge criteria including resolution or significant improvement of symptoms, no respiratory distress, and stable vital signs, as recommended by the American College of Chest Physicians 3

Prevention and Risk Reduction

• Smoking cessation counseling should be emphasized to reduce the risk of recurrence, as recommended by the British Thoracic Society 2