Atraumatic Tension Pneumocephalus in a Shunted Patient: A Case of Rapid Neurological Decline

Pneumocephalus is a rare but potentially life-threatening condition caused by the presence of air within the intracranial cavity. It commonly arises from trauma, neurosurgical procedures, infections, malignancies, or spontaneous causes. In patients with ventriculoperitoneal (VP) shunts, pneumocephalus may result from complications such as altered cerebrospinal fluid dynamics or skull base defects leading to a vacuum-like effect. We report a case of an 83-year-old male with a history of VP shunt placement for normal pressure hydrocephalus who presented with acute neurological deterioration, including aphasia and quadriparesis. Imaging revealed severe frontal pneumocephalus with mass effect and midline shift. The patient underwent emergent burr hole evacuation and VP shunt removal. Despite surgical intervention, he developed a new sizable subdural hematoma, leading to further deterioration. Following a prolonged critical course and poor neurological recovery, the patient was transitioned to hospice care. This case highlights the potential for severe tension pneumocephalus in patients with VP shunts, emphasizing the need for early recognition and prompt neurosurgical management. Given the high morbidity associated with tension pneumocephalus, clinicians should maintain vigilance for this rare but serious complication.