Massive pneumocephalus after Valsalva maneuver in sphenoidal meningocele

Pneumocephalus, defined as the presence of gas within the intracranial space, typically results from head trauma, surgery, or diagnostic/therapeutic procedures that disrupt the dura. However, spontaneous or non-traumatic pneumocephalus is rare. This video article presents a case report of a 64-year-old woman referred to the Department of Otolaryngology with a severe frontal headache and clear nasal discharge (rhinorrhea) after performing the Valsalva maneuver to relieve ear fullness. The patient had previously been diagnosed with sphenoidal meningocele and was awaiting skull base reconstruction surgery. A computed tomography (CT) scan of the brain and paranasal sinuses revealed significant pneumocephalus, with a defect in the sellar floor and cerebrospinal fluid (CSF) pooling in the sphenoid sinus. An endoscopic trans-sphenoidal repair of the CSF leak was promptly performed, and a post-operative CT scan showed complete resolution of the pneumocephalus. At the 2-month follow-up, the defect had healed optimally, with no intracranial complications observed. Pneumocephalus is a rare clinical condition, and prompt, accurate diagnosis, along with early intervention, is crucial to prevent neurological complications.