Background and Aims Pneumocephalus (PC), defined as presence of air in the intracranial space, is a rare complication of neuraxial techniques. We describe a case of a pregnant woman submitted to a combined spinal-epidural (CSE) technique who developed PC with late presentation.

Methods 16-year old pregnant woman, 41 weeks of pregnancy, asked for labor pain relief. A CSE with loss of resistance with saline (LORS) technique was performed. The epidural catheter (EC) was used for analgesia during labor work, with complete pain relief and no complications. 9 hours after, the patient was submitted to urgent cesarean section (CS) because of nonreassuring fetal status. Shortly after the anesthetic bolus via EC, the patient developed apnea, coma and anisocoria and was promptly intubated and ventilated. At the end of CS the patient woke up without neurologic deficits. Cerebral CT scan showed air densities in the right lateral and third ventricle. Bedrest and oxygen therapy was instituted. She developed postural headache treated with analgesia and was discharged 8 days after, fully recovered.

Results PC is often associated with identification of epidural space trough loss of resistance to air (LORA). However, in this case we used LORS. Also, she developed postural headache in the postoperative period, which suggests a dural lesion. The air entrance through the dural defect to the intracranial cavity, during the epidural bolus, seems to be the most likely mechanism of PC.

Conclusions PC usually manifests with headache and resolves spontaneously, however presentation can be atypical and surgical treatment may be necessary in cases of tension PC.