Pneumocephalus Associated with Inappropriate Valsalva Technique

BACKGROUND: Pneumocephalus is intracranial air normally occurring as a consequence of trauma or cranial surgery, but rarely has been reported following the habitual use of the Valsalva maneuver. We were unable to locate any similar cases of pneumocephalus associated with high performance aircraft flight, and this case report highlights an important consequence of the inappropriate use of Valsalva on ascent to altitude.CASE REPORT: A healthy 29-yr-old F-22 instructor pilot presented with recurrent pneumocephalus following the use of the Valsalva maneuver. These episodes started after an initial use of a forceful Valsalva during an aggressive unrestricted climb to altitude. His symptoms included facial pressure and a bubbling sensation in his head followed by a severe headache for several days. After upright CT evaluation, three small sphenoid sinus defects were discovered and repaired. There was no recurrence of pneumocephalus following provocative testing after surgical repair of the sphenoid sinus defects, and the aviator returned to flying high performance aircraft.DISCUSSION: Spontaneous or Valsalva-associated pneumocephalus is an uncommon occurrence in healthy individuals. Awareness of the pathognomonic succussion splash associated with this diagnosis as well as a presentation of facial pressure and headache following flight will lead to appropriate diagnostic investigation and management. This case highlights the importance of recognizing rare diagnoses like pneumocephalus in the flying population, and future education of aerospace physiology technicians and aviators should emphasize appropriate Valsalva technique to promote flying safety and prevent similar presentations.Woodside SS, Metzler MM. Pneumocephalus associated with inappropriate Valsalva technique. Aerosp Med Hum Perform. 2019; 90(6):566–569.