Intraoperative development of tension pneumocephalus in a patient undergoing repair of a cranial-dural defect under nitrous oxide anesthesia

Rapid buildup of gas within the cranial vault can result in a life-threatening condition known as 'tension pneumocephalus,' necessitating immediate surgical intervention. Nitrous oxide (N₂O), a commonly used inhaled anesthetic, is associated with the development of tension pneumocephalus and its role in neurosurgical procedures has been debated in the literature. We present a case of tension pneumocephalus with preexisting pneumocephalus secondary to the usage of N₂O as an inhaled anesthetic. Included is a literature review of studies discussing the role of N₂O in the development of tension pneumocephalus. N₂O is associated with tension pneumocephalus especially in the setting of preexisting pneumocephalus. Tension pneumocephalus can manifest as Cushing response and immediate decompression is life-saving. Nitrous oxide should be used cautiously in neurosurgical procedures, especially with preexisting pneumocephalus.