Nothing to sneeze at: tension pneumocephalus causing an acute stroke following endoscopic sinus surgery

Pneumocephalus is a rare condition caused by abnormal air entrapment in the intracranial compartment following disruption of the meninges. Most cases self-resolve and typically do not cause neurological sequelae. However, excessive expansion of the pneumocele results in rapid neurological deterioration, termed tension pneumocephalus. Left untreated, this leads to tissue ischemia, herniation syndromes, and death. Rapid differentiation between the above entities and immediate multimodal management dictate the success of recovery. The author reports an exceptional case of an 82-year-old male who presented to an outside hospital with focal neurological deficits in the early postoperative period following endoscopic sinus surgery. Computed tomography imaging revealed a large pneumocele resulting in severe mass-effect on the underlying brain parenchyma. Prompt surgical evacuation of the pneumocele resulted in dramatic recovery with only minor disability from the initial ischemic insult. Tension pneumocephalus is an uncommon, albeit life-threatening neurosurgical emergency wherein the developing pneumocele results in abnormally high intracranial pressure. Prompt recognition by emergency physicians and appropriate management are critical to limit further morbidity and mortality.