Tension Pneumocephalus From an Eroding Cholesteatoma: A Case Report and Review of the Literature

Pneumocephalus is defined as the presence of air inside the cranial vault. Benign and tension pneumocephalus are different ends of the same disease spectrum. Tension pneumocephalus leads to the formation of a pressure gradient, requiring emergent surgical decompression to prevent herniation of the intracranial structures. In this report, we present a rare case of tension pneumocephalus with essentially benign radiological findings secondary to a ruptured cholesteatoma. The patient was a 64-year-old woman with a history of end-stage renal disease on hemodialysis and hypertension. She presented to the emergency department (ED) with acute-onset weakness and decreased mentation. Physical exam findings were consistent with a cerebrovascular accident (CVA). CT scan and CT angiogram (CTA) were unremarkable for ischemia or hemorrhage but showed signs of free intracranial air, consistent with the diagnosis of pneumocephalus. After the activation of the code stroke, neurosurgery and neurology were consulted. Worsening respiratory status led to a decision to proceed with emergent intubation, but it was held based on the family’s decision to proceed with comfort measures. The patient’s status declined further within minutes and she died. Afterward, the case was discussed with the radiologist, who interpreted the cause as a cholesteatoma that had eroded through the temporal bone.