Introduction:
Pneumocephalus is a rare phenomenon, typically resulting from traumatic or non-traumatic causes. It could however occur spontaneously, in the absence of an underlying condition or from manipulation of a venous catheter resulting in retrograde movement of air against the direction of blood flow causing fatality [1-4]. It occurs in less than 3 per 100,000 hospitalizations [5]. This case reports possible etiologies of a rare case of pneumocephalus resulting in a stroke.

Materials and Methods:
A review of chart and verbal consent from patient’s family prior to reporting case.

Results and Discussion:
We present a 76-year-old African American female with End Stage Renal Disease who presented to the ED for altered mental status, following an episode of bleeding during a hemodialysis (HD) completed via the internal jugular vein through a tunneled dialysis catheter. Neurological examination revealed signs of a massive stroke including a right lateral gaze, with 3+ reflexes in the upper extremities bilaterally. Head CT scan revealed moderate amounts of air within the right frontoparietal sulci, minute intraparenchymal foci of gas within the venous structures; interval gray-white loss involving the right frontoparietal lobe and right centrum semiovale, with watershed involvement. Echo cardiogram revealed no wall or valvular defect. She was not deemed appropriate for Hyperbaric oxygen and discharged to a palliative care facility by family.

Conclusions: While some causes of pneumocephalus have previously been documented in literature, unusual etiology can lead to diagnostic dilemma and calls for a high level of suspicion by healthcare providers