Background: Pneumocephalus is a recognized complication from head and facial traumas, sinus surgery and as a complication from otitis media acuta. Only a few cases of pneumocephalus related to diving have been reported.
History: We report an occupational diver who suffered spontaneous subarachnoidal pneumocephalus related to a dive to 20 meters. At a depth of 17 msw he suffered from sudden onset of headache, dizziness, nausea and feeling of disorientation. He had no recognized risk factors such as documented facial fractures, rapid ascent or blocked sinuses. CT showed air in the subarachnoidal space. Otoneurological tests revealed pathological smooth pursuit tracking eye movements and substantial imbalance indicating a central neurological injury. CT and MRI showed a bony defect in the sphenoid sinus covered only by arachnoidea. This was probably the communicative fistula for the entrance of air. On follow-up examination one year later he still had central nervous symptoms and signs, as well as symptoms of post-traumatic stress disorder (PTSD.) He was not able to do any work and was declared unfit for further diving. We chose not to treat him with hyperbaric oxygen (HBO2) in the acute state because we thought HBO2 might have increased the amount of intracranial air.
Conclusion: Pneumocephalus is a rare, but serious complication of diving. The condition should be suspected in a diver with increasing headache or other central nervous disturbancies during ascent. The treatment of pneumocephalus in divers is a matter of debate.