Severe pneumocephalus following cranioplasty: Approach and review of the literature

Objective: To present a case of significant persistent pneumocephalus following failed cranialization of the frontal sinus. Case report: We describe the case of a 58-year-old female with a history of hemorrhagic stroke requiring emergent craniotomy which was complicated by inadvertent entry into the frontal sinus. Immediate occlusion of the frontal duct was performed with temporalis muscle and fascia, however the patient developed persistent pneumocephalus. She then underwent formal frontal sinus cranialization yet continued to demonstrate significant pneumocephalus. CT head (CTH) demonstrated extensive bilateral frontal pneumocephalus with a small defect in the floor of the frontal sinus at the level of the outflow tract. The patient underwent skull base repair with a nasoseptal flap with significant improvement in pneumocephalus. Conclusions: Chronic large volume pneumocephalus is a rare complication of intracranial procedures. We describe successful endoscopic closure of a small anterior skull base defect which persisted after attempted formal frontal sinus cranialization. Endoscopic repair of the anterior skull base is a valuable tool in the management of “failed” frontal sinus cranialization.