A 49-year-old man presented to the Emergency Department after being assaulted earlier in the day. The patient was reportedly kicked and beaten with a bat. The family reported that the patient had a loss of consciousness lasting 3 min. During the day he had one episode of vomiting, and became increasingly sleepy. Family members brought the patient into the Emergency Department approximately 15 h after the assault due to his being progressively sleepier. He reported a generalized headache and wished to go home. Vital signs were: blood pressure 110/80 mm Hg, pulse 78 beats/min, respiratory rate 18 breaths/min, temperature (oral) 36.5°C (98.2°F), and oxygen saturation of 100% on room air. On physical examination, the patient was lethargic and restless at times but orientated to person, place, and time. He was photophobic, had a superficial scalp laceration, and a laceration on the left wrist. Extraocular movements were intact, all cranial nerves were intact, and there were no motor or sensory deficits. An emergent computed tomography (CT) scan of the head was obtained due to the increasing lethargy.On CT scan the patient was found to have pneumocephalus (Figure 1). There was a suggestion of frontal sinus fracture resulting in the pneumocephalus. Pneumocephalus can be due to posterior fossa craniotomies, transsphenoidal surgery, traumatic skull fracture, thoracotomy, nasopharyngeal tumor invasion, valsalva maneuver, spinal fractures, meningitis, and rarely, after air travel (1,2). Headache and altered consciousness are the most common symptoms. Tension pneumocephalus can occur if intracranial air leads to mass compressing brain, and is a true neurosurgical emergency requiring emergent evacuation of air. Signs of tension pneumocephalus include deterioration of consciousness, restlessness, generalized convulsion, or focal neurologic deficit (3). Our patient was scheduled for neurosurgical evacuation of
