Pneumocephalus Following Thoracic Surgery with Posterior Chest Wall Resection Ina Müller 1 Mario Tönnies 1 Joachim Pfannschmidt 1 Dirk Kaiser 1 1 Department of Thoracic Surgery, Helios Klinikum Emil von Behring, Berlin, Germany Thorac Cardiovasc Surg Rep 2015;4:5–7. Address for correspondence Ina Müller, MD, Department of Thoracic Surgery, Helios Klinikum Emil von Behring, Walterhöferstrasse 11, Berlin 14165, Germany (e-mail: ina.mueller83@hotmail.com; ina. mueller@helios-klinken.de). Introduction Pneumocephalus following thoracic surgery was first re- ported in 1974 and since then it has been rarely described. Most commonly, pneumocephalus can be seen after head injury with fracture of the skull-base or in cerebral neoplasm, infection, or after intracranial or spinal surgery. We describe a case of pneumocephalus after thoracic surgery with posterior chest wall resection and the necessity of neurosurgical operation. A 69-year-old patient was admitted to hospital with pain in the right thoracic side and the right shoulder. Computer tomography of the chest showed a T3-tumor in the right upper lobe with local infiltration of the posterior chest wall. A CT-guided biopsy was obtained for histological examination, which showed a poorly differentiated squamous cell lung cancer. The patient received two cycles of neoadjuvant che- motherapy with cisplatin plus vinorelbine and radiotherapy with 45 Gy. Subsequently, the tumor size decreased and the patient underwent surgery (►Fig. 1). Posterolateral thoracot- omy was performed with en bloc resection of the right upper lobe and the involved ribs T2 to T4. Disarticulation of the costotransversal and costovertebral joints were necessary and chest wall reconstruction was done by Gore-Tex (W.L. Gore & Associates, Inc., Arizona, United States) dual-mesh prosthesis. For pain relief, our patient received a thoracic epidural catheter preoperatively. On the first postoperative day, the patient presented with a sudden reduced vigilance level, no response to pain stimuli, and anisocoria. CT of the head showed an extensive pneumo- cephalus of both hemispheres with a collection of free air in the lateral ventricles (►Fig. 2). The epidural catheter was removed at once to exclude one of the possible causes for postoperative pneumocephalus. After two days of conserva- tive therapy with bed rest in strict supine position of the head and body, the patient was conscious without anisocoria. Meanwhile, the patient developed a right-sided pneumonia and consecutive antibiotic therapy was administered. There was a rapid improvement in the patient’s condition with the exception of persistent headache and vertigo. Assuming that intracranial hypotension was created by a cerebrospinal fistula, the patient was transferred to the neurosurgical department. In addition, it was assumed that there was an epidural leakage due to the puncture for epidural catheter placement, thus an epidural blood patch by autologous donation was made. However, despite the blood patch, the Keywords ► thoracic surgery ► chest wall ► lung cancer treatment (surgery medical) ► neurology/neurologic (deficits disease injury) Abstract Pneumocephalus can be seen after head injury with fracture of the skull-base or in cerebral neoplasm, infection, or after intracranial or spinal surgery. We report on a 69-year-old male patient with pneumocephalus after right-sided lobectomy and en bloc resection of the chest wall for non-small-cell lung cancer. Postoperatively, the patient showed a reduced vigilance level with no response to pain stimuli and anisocoria. The CCT scan revealed an extensive pneumocephalus; following which, the patient under- went neurosurgery with laminectomy and ligature of the transected nerve roots. After operation the patient returned to his baseline mental status. received July 27, 2014 accepted after revision October 28, 2014 published online January 20, 2015 DOI http://dx.doi.org/ 10.1055/s-0034-1396683. ISSN 2194-7635. © 2015 Georg Thieme Verlag KG Stuttgart · New York THIEME Case Report: Thoracic 5