Images in Clinical Medicine
Pneumocephalus Associated with Pneumosinus Dilatans Frontalis
N Engl J Med 2007; 357:1136September 13, 2007
- Article
An 87-year-old woman presented to the emergency department with an acute-onset severe global headache of 36 hours' duration, with greater occipital involvement than frontal involvement. She reported no recent trauma, prior sinus surgery or sinusitis, fevers, chills, neck stiffness, or photophobia, and she had no clinically relevant medical history. Physical examination showed that she was afebrile, alert, and oriented, with a supple neck. Her neurologic examination, including funduscopy and a leukocyte count, was normal. Computed tomography of the head and paranasal sinuses revealed pneumocephalus involving the anterior and middle cranial fossae (Panel A), without evidence of herniation. In addition, there was enlargement of the frontal sinus, more on the right side than on the left, with extreme thinning of the bony posterior table (Panel B, arrow). A diagnosis of pneumocephalus associated with pneumosinus dilatans of the frontal sinus was made. The patient was offered surgery but refused any intervention. She was discharged, without medications, after a 24-hour regimen of empirical antimicrobial therapy and observation, during which there was no deterioration. At follow-up 4 weeks later, the patient was asymptomatic; repeat imaging showed complete resolution of the pneumocephalus.
Neil Bhattacharyya, M.D.
Robert M. Friedlander, M.D.
Brigham and Women's Hospital, Boston, MA 02115
neiloy@massmed.org
