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Tension Pneumocephalus — FRCA Final MCQ

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HardNeuroanaesthesiaTension PneumocephalusFRCA Final

A 55-year-old woman develops worsening headache, vomiting and increasing drowsiness 3 days after a sitting-position craniotomy for meningioma excision. CT demonstrates bilateral frontal subdural air collections compressing and separating the frontal lobes, with widening of the interhemispheric space. Which diagnosis and management pair is most appropriate?

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Correct answer: D — Tension pneumocephalus; urgent neurosurgical decompression

The correct answer is D. Bilateral frontal subdural air that compresses and separates the frontal lobes, widening the interhemispheric space, is the Mount Fuji sign. In a patient with worsening headache, vomiting and reduced consciousness, it indicates tension pneumocephalus: intracranial gas under pressure producing mass effect. This is a neurosurgical emergency requiring urgent decompression, with high-concentration oxygen as an adjunct and avoidance of nitrous oxide. Simple or expected postoperative pneumocephalus may be observed when there is no neurological deterioration or significant mass effect; it does not produce frontal-lobe separation. A subdural empyema would be suggested by an infected fluid collection and systemic inflammatory features rather than bifrontal gas. CSF loss may contribute to air entry after sitting-position surgery but does not make dural-leak management alone sufficient once tension physiology has developed.

Reference: Harvey JJ, Harvey SC, Belli A. Tension pneumocephalus: the neurosurgical emergency equivalent of tension pneumothorax. BJR Case Reports. 2016;2(2):20150127. https://pubmed.ncbi.nlm.nih.gov/30363668/