Pneumocephalus, commonly seen after trauma, surgical intervention, or meningitis, is rarely associated with ventriculoperitoneal shunt (VPS) procedures. We present a unique case of tension pneumocephalus in a 26-year-old female who experienced two distinct episodes of pneumocephalus. She presented with right-sided facial numbness, hearing loss, blurry vision, and gait disturbance. Magnetic resonance imaging (MRI) revealed a large extra-axial lesion at the right petrous apex extending to the middle cranial fossa. The patient underwent an extended endoscopic endonasal approach for tumor resection, and the pathological diagnosis revealed an epidermoid cyst. Postoperatively, she improved. However, she developed abducens nerve palsy followed by extensive pneumocephalus with intraventricular extension, necessitating skull base defect repair. Six weeks later, she presented with acute hydrocephalus secondary to meningitis from