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580 Case Report / Journal of Clinical Neuroscience 15 (2008) 580582

and travel, entering into the ventricles, and becoming at- sa with conrming histological characteristics. Care should
tached to the ventricular wall. This hypothesis could be indi- be taken to prevent the spread of cystic content into the
rectly supported by this case. CSF pathways during epidermoid removal.
Since the rst report in which Maravilla5 presented nd-
ings on intraventricular fat-uid level secondary to the
spontaneous rupture of a dermoid cyst, a number of
reports have noted the spread of fat globules into CSF 1. Wasenko JJ, Rosenbloom SA, Estes M, et al. Magnetic resonance of
pathways in patients with fat-containing tumors such as intracranial epidermoids. Eur J Radiol 1991;13:1036.
epidermoid or a dermoid tumors.5,6 To the best of our 2. Lopes M, Capelle L, Duau H, et al. Surgery of intracranial
knowledge, there has been no prior report regarding ecto- epidermoid cysts. Report of 44 patients and review of the literature.
Neurochirurgie 2002;48:513.
pic recurrent tumor tissue within the ventricle, which has
3. Samii M, Tatagiba M, Piquer J, et al. Surgical treatment of
been histologically proven to be an epidermoid cyst. Epi- epidermoid cysts of the cerebellopontine angle. J Neurosurg 1996;84:
dermoid cysts in the CSF pathways secondary to spontane- 149.
ous rupture may be widespread. In cases of multiple 4. Guidetti V, Gagliardi FM. Epidermoid and dermoid cysts: Clinical
intracranial epithelial cysts, dissemination of the epithelial evaluation and late surgical results. J Neurosurg 1977;47:128.
5. Maravilla KR. Intraventricular fat-uid level secondary to rupture
clusters into the CSF could reasonably be explained by
of an intracranial dermoid cyst. AJR Am J Roentgenol 1977;128:
asymptomatic rupture or spontaneous breakdown of the 5001.
cyst wall. 6. Kwon TH, Park YK, Chung HS, et al. Accumulation of intraventric-
In summary, we report an unusual case of ectopic ven- ular fat in an intracranial epidermoid tumor: Case report. Neurosurgery
tricular recurrence of an epidermoid cyst in the middle fos- 2001;49:4502.


Tension pneumothorax complicating apnea testing during

brain death evaluation
Joseph D. Burns *, James A. Russell
Department of Neurology, Lahey Clinic Medical Center, Burlington, MA 01805, USA

Received 3 November 2006; accepted 4 February 2007


Tension pneumothorax is a rare complication of the apnea test using the apneic oxygenation method. In reported cases, it has been
attributed to massive air trapping beyond a supplemental oxygen cannula that was obstructing the airway. We report a case of tension
pneumothorax, pneumomediastinum, and pneumoperitoneum that developed during the apnea test as a result of direct airway perfora-
tion by the supplemental oxygen cannula. We review the literature concerning catastrophic airway complications associated with the
apneic oxygenation method and suggest ways to avoid them.
2007 Elsevier Ltd. All rights reserved.

Keywords: Apnea test; Brain death; Pneumothorax

Apnea testing is an essential element of the evaluation a cannula placed in the endotracheal tube (ETT), is the
for death by neurological criteria. The apneic-oxygenation recommended method for performing this test.1 A high
method, during which supplemental oxygen is provided by incidence of complications has been described in asso-
Corresponding author. Address: 3074 Avalon Cove Court NW ciation with this method, primarily hypotension and
Rochester, Minnesota 55901, USA. Tel.: +1 781 744 5102; fax: +1 781 hypoxemia.24 Infrequently, more serious complications
744 5243. including cardiac arrest, cardiac arrhythmia, and pneumo-
E-mail addresses: joseph.d.burns@lahey.org (J.D. Burns), james.a. thorax have been reported.27 We describe the incidence of
russell@lahey.org (J.A. Russell).
Case Report / Journal of Clinical Neuroscience 15 (2008) 580582 581

tension pneumothorax, pneumomediastinum, and pneu-

moperitoneum leading to pulseless electrical activity that
occurred during performance of apnea testing using the
apneic-oxygenation method. We review the literature
regarding such airway catastrophes and suggest methods
to avoid them.

1. Case report

A 55-year-old woman with a past medical history

notable for type 2 diabetes, pancreatitis, chronic renal
insuciency, myocardial infarction, and a cryptogenic left
occipital ischemic stroke, was admitted for abdominal
pain. She was found to have a small bowel infarction
and underwent resection of the infarcted segment on hos-
pital day 1. Her postoperative course was complicated by
failure to wean from the ventilator. On post-operative Fig. 1. Portable anterior-posterior chest X-ray showing a left pneumo-
day 4 she was noted to have decreased arousal and new thorax, pneumomediastinum, pneumoperitoneum, extensive subcutaneous
left hemiparesis. A CT scan of the brain revealed a large air, and a low-lying endotracheal tube.
right middle cerebral artery infarct with substantial ede-
ma and mass eect. Over the next 2 days, her alertness
progressively declined and spontaneous breathing
stopped. On post-operative day 6, the neurology service mothorax, pneumomediastinum, and pneumoperitoneum.
was asked to determine if the patient was dead by neuro- No overt breach was found in the wall of the trachea or
logical criteria. proximal mainstem bronchi.
At the time of brain death evaluation, she was normo-
thermic and unresponsive to loud verbal and noxious tac-
tile stimuli. The pupils were 5 mm diameter, round, and 2. Discussion
did not react to light. The oculocephalic reex was absent
and sequential irrigation of each external auditory canal Apnea testing is technically challenging and has been
with 60 cc of ice water did not cause deviation of the eyes. associated with a high rate of complications. In the few
The corneal reex was absent bilaterally, there was no gri- studies that have examined this topic, complication rates
mace or limb movement to noxious styloid pressure, and as high as 68% have been found.4 Hypotension attributed
there was no cough or gag to endobronchial suctioning to hypoxemia is one of the most common of these compli-
or manipulation of the ETT. cations.2 Accordingly, methods to minimize hypoxemia
Apnea testing using the apneic oxygenation method have been devised. One such method, described in the
was attempted. Pre-apnea test arterial blood gas analysis American Academy of Neurology Practice Parameters
showed a pH of 7.43, a carbon dioxide tension (PCO2) of on determining brain death in adults and known as apneic
43 mmHg, and an oxygen tension (PO2) of 144 mmHg. oxygenation, involves the provision of high-ow oxygen
Pre-oxygenation with FiO2 (fraction of inspired oxygen) into the endotracheal tube by means of a cannula placed
of 100% was performed for approximately 5 min before at the level of the carina.1
the ETT was disconnected from the ventilator. Next, a We believe that the insertion of an oxygen cannula
nasal cannula from which the nasal prongs had been re- into a deeply positioned ETT led to the complications de-
moved was inserted into the number 7 ETT. Oxygen was scribed in our patient. She had no history of chronic
delivered at a rate of 10 L/min. Rapidly expanding sub- obstructive pulmonary disease, elevated peak airway pres-
cutaneous emphysema in the neck and chest wall oc- sures, bullae or other lung pathology noted on prior chest
curred immediately after insertion of the cannula. lms that would have predisposed her to lung rupture.
Within seconds, the patient developed pulseless electrical Rather, because subcutaneous emphysema became mani-
activity. fest immediately after insertion of the oxygen cannula,
The ETT was immediately reconnected to the ventilator, it is likely that the cannula went beyond the distal end
which measured very high inspiratory pressures. Manual of the ETT and perforated either the distal trachea or
ventilation was initiated. An emergency chest lm revealed the left mainstem bronchus. The deep position of the
a large left pneumothorax, pneumomediastinum, pneumo- ETT may have predisposed this patients carina to recur-
peritoneum, and extensive subcutaneous emphysema rent trauma during routine suctioning, thus rendering it
(Fig. 1). The distal end of the ETT was within 1 cm of susceptible to puncture by the blunt, silastic oxygen
the carina. Autopsy results conrmed the presence of pneu- cannula.
582 Case Report / Journal of Clinical Neuroscience 15 (2008) 582585

This mechanism is dierent from that postulated in pre- Acknowledgement

viously published reports of similar cases. In the two cases
described by Bar-Joseph et al., the development of brady- The authors thank Dr. Allan Ropper for his thoughtful
cardia and hypotension lagged behind the introduction of guidance and support in the preparation of this paper.
the oxygen cannula by 12 min.5 This led the authors to
conclude that in their cases, tension pneumothorax devel-
oped as the result of massive air trapping beyond a cannula References
that was obstructing the airway. A similar explanation was
1. The Quality Standards Subcommittee of the American Academy of
used to explain the development of subcutaneous emphy- Neurology. Practice parameters for determining brain death in adults.
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ein as part of a case series examining the ecacy of the 2. Goudreau JL, Widjicks EFM, Emery S. Complications during apnea
apneic oxygenation method in preventing hypoxemia.6 testing in the determination of brain death: predisposing factors.
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3. Melano R, Adum ME, Scarlatti A, et al. Apnea test in diagnosis of
rax and pneumoperitoneum followed by cardiac arrest that brain death: comparison of two methods and analysis of complica-
occurred 2 min after the oxygen cannula was inserted tions. Transplant Proc 2002;34:112.
during apneic oxygenation.7 The onset of subcutaneous 4. Saposnik G, Rizzo G, Vega A, et al. Problems associated with the
emphysema immediately after insertion of the oxygen can- apnea test in the diagnosis of brain death. Neurol India 2004;52:3425.
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apnea testing for the determination of brain death. Anesthesiology
patient. 1998;89:12501.
Our patient serves as a dramatic example of the poten- 6. Marks SJ, Zisfein J. Apneic oxygenation in apnea tests for brain
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the high rate of complications associated with the apneic 7. Saposnik G, Rizzo G, Deluca JL. Pneumothorax and pneumoperi-
oxygenation method, some of which are catastrophic, other toneum during the apnea test: how safe is this procedure? Arq
Neuropsiquiatr 2000;58:9058.
potentially safer apnea testing methods such as articial 8. Sharpe MD, Young BG, Harris C. The apnea test for brain
carbon dioxide augmentation should continue to be inves- death determination: an alternative approach. Neurocrit Care
tigated.2,8 If the apneic oxygenation method is used, we 2004;1:3636.
strongly discourage the insertion of an oxygen cannula into 9. al Jumah M, McLean DR, al Rajeh S, et al. Bulk diusion apnea test
the ETT. Safer, yet equally eective methods for providing in the diagnosis of brain death. Cri Care Med 1992;20:15647.
10. Levesque S, Lessard MR, Nicole PC, et al. Ecacy of a T-piece
supplemental oxygen, including bulk diusion, T-piece sys- system and a continuous positive airway pressure system for
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should be used instead.9,10 2006;34:22136.


Malignant cerebellar ganglioglioma

Marguerite Harding *, Brian Brophy, Timothy Geake
Department of Neurosurgery, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000, Australia

Received 27 September 2006; accepted 5 February 2007


We present a 62-year-old man with a high-grade cerebellar ganglioglioma with ataxia. Gangliogliomas are rare tumours which usually
occur in the rst 3 decades of life. There have only been a small number of grade IV gangliogliomas reported in the literature.
Crown Copyright 2007 Published by Elsevier Ltd. All rights reserved.

Keywords: Ganglioglioma; Cerebellar; Glioblastoma multiforme; High grade

Corresponding author. Tel.: +61 0434603319; fax: +61 882225886.
E-mail addresses: mhardin1@mail.rah.sa.gov.au (M. Harding).