1 Introduction
We read with great interest the recent Article by Harlyjoy et al. () focusing on the management of traumatic tension pneumocephalus (TP) and the associated challenges in treating patients with head trauma in low- and middle-income countries (LMICs) (). The authors' exploration into optimizing treatment protocols to reduce hospitalization times and minimize post-operative complications is both timely and pertinent. They notably underscore the critical need to address delays in the management of traumatic brain injuries by enhancing the utilization of health resources. We would like to provide our insights based on our experience in managing TP caused by post-traumatic ethmoidal damage, further contributing to this essential dialogue.
2 Discussion
While Pneumocephalus is a condition characterized by the presence of air in the intra cranial space caused by a breach in the cranium dural barrier, in TP air is progressively accumulated in the intra cranial space by a “ball valve” or “inverted pop bottle” mechanism. This mechanism categorizes TP as emergency condition due to the compressive effect of the trapped air on the brain. In the management of TP, the primary objective is the emergent decompression to alleviate intracranial pressure, combined with the repair of the causative defect (). Endoscopic multilayer repair is the standard treatment for closing the craniodural breach. To achieve adequate intracranial decompression, the historical craniectomy has been replaced with the more recent craniotomy (). Despite its efficacy, craniotomy is associated with a notable risk profile including soft tissue infection, extradural abscesses, subdural empyema, bone flap infection, and postoperative intracranial infection (). Shi et al. () reported their experience with post craniotomy intracranial infection (PCII), showing a PCII rate of 6.8% among 5,732 patients.
Recent studies have explored various endoscopic techniques that simultaneously address the resolution of traumatic tension pneumocephalus (TP) and the closure of the bone defect responsible for cerebrospinal fluid leakage in a single surgical stage (, ). The development of new techniques and more angulated instruments for endoscopic surgery has increased the possibility of accessing more challenging endonasal areas (). Single-step endonasal procedures may effectively treat both the TP and the craniodural defect concurrently, significantly lowering the risks of complications and shortening the duration of hospital stays. Patients treated with these strategies can expect reduced postoperative morbidity, quicker discharge, and a faster return to work. This is particularly relevant in LMICs, where the healthcare infrastructure may not support extensive postoperative care, and where the economic impact of prolonged hospitalization can be substantial.
To the best of our knowledge, the literature offers only four examples of TP resulting from post-traumatic ethmoidal roof damage, complicating the development of precise management guidelines. However, with equal effectiveness, the more appropriate direction should focus on procedures that allow a reduction in post-operative hospital stays and complications rate.
In conclusion, the adoption of endonasal endoscopic approaches for the first-line treatment of symptomatic TP due to post-traumatic ethmoidal defects offers a promising opportunity to improve patient outcomes not just in LMICs, but globally. This method underscores the potential of minimally invasive surgical techniques in TP management, promoting a model that prioritizes efficiency, safety, and accessibility while addressing the challenges of limited healthcare infrastructure and resources.
Statements
Author contributions
GLO: Writing – review & editing. RM: Writing – original draft, Writing – review & editing. GV: Writing – review & editing. BF: Writing – review & editing. SSA: Writing – review & editing. ASA: Writing – review & editing. SD: Writing – review & editing.
Funding
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
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Summary
Keywords
tension pneumocephalus, endoscopic endonasal, head trauma, craniotomy, ethmoidal defect
Citation
Omer GL, Maurizi R, Velletrani G, Francavilla B, Ali SS, Abdullah AS and Di Girolamo S (2024) Traumatic tension pneumocephalus: a case report and perspective from Indonesia. Front. Neurol. 15:1391270. doi: 10.3389/fneur.2024.1391270
Received
25 February 2024
Accepted
18 April 2024
Published
03 May 2024
Volume
15 - 2024
Edited by
Andrew P. Lavender, Federation University Australia, Australia
Reviewed by
Givago Silva Souza, Federal University of Pará, Brazil
Updates
Copyright
© 2024 Omer, Maurizi, Velletrani, Francavilla, Ali, Abdullah and Di Girolamo.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Riccardo Maurizi riccardomaurizi1994@gmail.com
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.