Pneumocephalusin Association with LumbarPunctures

The article by Jarjour and Wilson (Chest 1989; 96:1425-26) on pneumocephalus associated with nasal continuous positive pressure ventilation in a patient with sleep apnea syndrome was of particular interest to us. Recentk@ we noted the development of pnetimoce phalus in a patient admitted to the pulmonary/ICU service who had undergone multiple lumbar puncture attempts. A literature search revealed no report of pneumocephalus in association with lumbar punctures. A 48-year-old actor was admitted to the hospital with penile trauma, lethargy and altered mentation. His medical history was significant for Cilles de Ia T()urette syndrome and a spinal injury sustained during childhood. His medications included haloperidol and pimozide. On presentation, he was alert with occasional lapses into incomprehensible, pressured speech. Physical examination was significant for gross blood from urethra and al)rasion of the right scrotum. There was mild nuchal rigidity hut other nieningeal signs were al)sent. There was no external evidence of head trauma. Complete I)lO()d cxunts, blood biochemical studies and thyroid function test results were normal. Urologic evaluationi revealed a hulhar urethral hematoma, and a sniprapuhic catheter was placed. An emergency CT scan of the head that included windows of the l)ase of the skull was normal. Multiple (approximately 30) lumbar punctures were attempted by several physicians. hut no fluid was obtained. All attempts were made with the patient psitioned horizontally in the lateral decuhitus p@)siti@n. No accidental or deliberate intr(xluction of air into the suharachnoid space was reported b@any ofthe physicians attempting spinal tap. The patient was empirically started on l)road spectrum antibiotic therapy for possible bacterial meningitis, with a plan to obtain cerebrospinal fluid tinder fluoroscopy the subsequent morning. His mental status deteriorated rapidly during the night and he was transferred to the ICU . CT scan of the head was repeated using contrast medium and revealed pneumocephalus in the region of the right frontal lobe of the brain (Figure). A lateral view of the skull also showed pneumo cephalus. The patient underwent successful lumbar ;)tinctnire tinder fluo r@@copythe next morning. The cerebro-spinal fluid revealed no evidence of meningeal infection. A toxicology screen obtained on admission was positive for cocaine in the urine, and blood cultures were positive for Staphylococcus aureus. The patient's mental status improved steadil): A third CT scan of the head ol)taine(l three days after the second showed no pneumocephalus. The patient was discharged from the hospital a few days later. Although pneumocephalus has been repcrted in association with head trauma. mask CPAP. nasal CPAP, and rapid ascent to the surface by scuba divers,'' it has not heen reported to occur with lumbar punctures. In fact, repeated lumbar taps have been used to treat increased intracranial pressure due to pneumocephalus.@@ Our case shows that, in a case where lumbar puncture is difficult, it is probably more prudent to do the procedure tinder fluoroscopy rather than risk a pneumocephalus and its manifestations.