If someone were to say, "He is such an air head" or "He's lost his mind" that would be considered a pretty rude insult. In the case of one recent patient in Northern Ireland however, it was, at least in part, accurate.
A general practitioner there wrote a case report for the British Medical Journal about a patient who presented with balance problems and one-sided weakness that turned out to be caused by a rare neurological phenomenon that even most neurosurgeons do not see that often.
Dr. Finlay Brown wrote the report on an 84-year-old patient of his who experienced a few months of falls and trouble staying balanced when walking. It's not unusual for this to happen in elderly patients, but this man was healthy, did not smoke, rarely drank and was not taking medications that could have caused the symptoms. Initially, doctors felt it was likely a stroke, but the patient did not have any facial weakness, trouble speaking or any visual disturbances. When images taken via CT and MRI scans were reviewed the problem became quite apparent. There was an air pocket, more than 3 inches long, that was compressing the frontal lobe of his brain.
Air pockets in the brain are called pneumatoceles and often arise because of trauma, but the patient denied any previous surgery or illness. This patient's problem was likely caused by a small osteoma, or bony tumor, that formed between the paranasal sinuses and the cranial cavity. The mass was beginning to wear away the base of the skull, leaving a small opening where air could leak into the cranial cavity. This causes a condition called pneumocephalus, and it was likely the pressure of the air in the cranial cavity that led to a small stroke, which in turn caused the patient's gait instability.
Usually, the osteoma could be removed via surgery, but a frontal craniotomy and delicate surgery to repair the hole in the skull is a significant undertaking. At any point, there could be complications that would make the man's condition worse or even endanger his life. The patient opted not to have the surgery, and his doctors are treating him conservatively, with medications to avoid a second stroke. After twelve weeks, the patient followed up, and the instability and weakness had improved. In an article published by CNN, Dr. Brown explained, "After discussion with the stroke specialists, it was felt that his small stroke was most likely secondary to the compressed effect the air pocket was having on his brain's blood supply, leading to a lack of blood and subsequent stroke. We managed the patient with his acute stroke and kept him comfortable while awaiting specialist input. It is very unlikely I will ever see the same findings again in another patient, but it does encourage doctors to have a low threshold for imaging even when facing very common presenting symptoms."
Each year in the United States there are approximately 795,000 patients who experience a stroke. Of those, nearly 185,000 are repeat strokes. 75% of patients who have a stroke are over the age of 65. While many older adults have issues with balance and muscle weakness, even if it seems like typical age-related motor decline, the question of a brain infarction has to be considered.
Sources: British Medical Journal, CNN, The Internet Stroke Center
