Delayed Tension Pneumocephalus Following Low-Energy Craniofacial Trauma in an Elderly Patient: A Case Report

Pneumocephalus, the accumulation of air within the intracranial compartments, most commonly follows head trauma with a skull-base or paranasal sinus fracture.When air continues to accumulate through a persistent osteodural defect and produces mass effect with clinical deterioration, it becomes tension pneumocephalus, a neurosurgical emergency.We report the case of an 88-year-old man with a history of asthma who fell from standing height with a craniofacial impact during a three-day febrile gastrointestinal illness.After regaining consciousness at home, he developed progressive impairment of consciousness.The initial computed tomography (CT) scan, performed 48 hours after the fall, showed pneumocephalus with a basifrontal fracture involving the right orbital roof and lamina papyracea, in the setting of moderate traumatic brain injury (Glasgow Coma Scale (GCS) 10/15).Over the following 24 hours, his GCS decreased to 8/15, and repeat CT demonstrated tension pneumocephalus with a 9-mm midline shift and subfalcine herniation.Urgent frontal burr-hole decompression with subdural drainage achieved radiological improvement without recurrence.Neurological recovery did not follow.The patient remained comatose (GCS 7/15) with a new severe left-sided hemiparesis.His intensive care course was complicated by an asthma exacerbation with dynamic hyperinflation, KDIGO stage 3 acute kidney injury, and a cardiac arrest of uncertain mechanism.He required a tracheostomy and died in the intensive care unit on day 31.This case shows that established traumatic pneumocephalus may progress to tension pneumocephalus after a low-energy mechanism, and that any neurological decline in a patient with a skull-base fracture should prompt immediate repeat CT.Radiological success of decompression did not translate into neurological recovery, underscoring the weight of associated traumatic lesions and secondary systemic insults in elderly patients.