| Summary: | Introduction: Pneumocephalus is the presence of air in the intracranial space. When the air is mostly present in the ventricular system, it is also referred to as pneumoventricle. In some instances, air continues to accumulate over time, exerting mass effect over surrounding neurological structures and increasing intraventricular and intracranial pressures (tension pneumoventricle). If left untreated, this may lead to rapid deterioration of the level of consciousness, coma, herniation and death. Case presentation: We report the case of a patient with subarachnoid hemorrhage who developed tension pneumoventricle secondary to an iatrogenic cutaneous-ventricular fistula after placement of an external ventricular drain. A surgical technique to manage this condition by replacing air with saline in a non-traumatic manner is presented in detail. We also describe all the nuances and potential pitfalls of this technique. Conclusion: Tension pneumoventricle is a rare but concerning complication of intracranial procedures. When clinically indicated, expedited treatment by EVD placement allows intracranial decompression and slow replacement of the ventricular space with water.
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