Abstract
INTRODUCTION: Delayed pneumocephalus is exceptionally rare in children and may result from unrecognized skull base fractures with cerebrospinal fluid (CSF) leak. Prompt recognition is essential to prevent life-threatening complications. CASE PRESENTATION: A 13-year-old boy developed delayed pneumocephalus and meningoencephalocele after high-impact facial trauma with multifocal skull base defects (posterior frontal sinus wall, sphenoid, and anterior ethmoid). He underwent combined endoscopic endonasal and external osteoplastic repair with multilayer closure and a temporary lumbar drain. Recovery was uneventful with complete clinical and radiological resolution within four months. DISCUSSION: In the absence of pediatric-specific guidelines, management is often extrapolated from adult algorithms that favor a short conservative trial followed by CSF diversion or surgery for persistent leaks or high-risk features. In multifocal, complex defects, a hybrid endoscopic-osteoplastic strategy can provide precise localization and secure multilayer closure, and adjunctive lumbar drainage has been shown to further improve repair success. CONCLUSION: Clinicians should suspect delayed pneumocephalus when new neurological or rhinologic symptoms arise after pediatric craniofacial trauma. A combined endoscopic-osteoplastic approach is a safe and effective option for complex skull base defects in children.