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769: SPONTANEOUS PNEUMOCEPHALUS NOT YOUR AVERAGE HEADACHE

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Pneumocephalus is an intracranial gas collection resulting from trauma, surgical procedures and on rare occasions are spontaneous. When intracranial pressure increases from pneumocephalus patients may develop headache, nausea, vomiting, irritability and seizures. Tension pneumocephalus is defined as a continual increase in intracranial pressure resulting in neurologic deterioration and is a neurosurgical emergency requiring urgent decompression. Methods: We present a 71 year old woman who presented to the emergency department with the complaint of a headache. She reported walking into her kitchen and “feeling like her head was going to explode.” The pain was described as pressure-like, predominantly frontal and seven-outof-ten in severity without radiation. She reported the pain initiated and was worsened with lateral rotation and lateral flexion of her head. No medication or maneuvers relieved the pain. Patient reported an intermittent history of profuse sinus drainage for over 10 years of which she attributed to allergies. She denied any recent fall, trauma or surgical procedure. On presentation patient received a CT head for suspicion of subarachnoid hemorrhage. CT revealed pneumocephalus throughout the entire intracranial cavity. Imaging results and presenting symptoms were concerning for the development of tension pneumocephalus of left frontal lobe. Neurosurgery evaluated and stated no urgent surgical intervention was required as the patient remained neurologically intact and further expert review of imaging was not indicative of tension pneumocephalus. Otorhinolaryngology was consulted who recommended bed rest in fowler positioning of 30 degrees and avoidance of valsalva maneuvers. CT sinustract study was performed and no obvious anatomical defect was detected. Patient did indeed have CSF leakage located at the region of the right cribriform plate under 3D imaging nasal endocscopy. She receieved a nasal floor mucosal graft to repair the affected region to prevent recurrence. Patient underwent follow up imaging which revealed near spontaneous resolution of the pneumocephalus on hospital day prior to discharge. Results: This case demonstrated the importance of knowing when intervention on pneumocephalus is necessary for this uncommon cause of severe headache. This scenario is not often encountered by a critical care resident but knowledge of when and when not to act on a potential surgical emergency is paramount as presented in this case.