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Background and Aims Pneumocephalus and pneumoventricle are rare but serious complications of epidural anaesthesia, particularly following accidental dural puncture when air is used in the loss of resistance (LOR) technique. These can mimic post-dural puncture headache (PDPH), potentially delaying diagnosis and treatment. We report a rare case of pneumoventricle in a high-risk patient following inadvertent dural puncture during lumbar epidural placement.Methods A 46-year-old hypertensive male with a past cerebrovascular accident was posted for elective renal transplant under combined epidural and general anaesthesia. During lumbar epidural placement at L1-L2 in the sitting position, an accidental dural puncture occurred using air for LOR. The epidural catheter was re-sited at another level. Headache developed immediately and was treated with intravenous paracetamol and fluids. General anaesthesia was administered and surgery completed uneventfully. Toward the end of surgery, the epidural catheter was activated with 15 mL of 0.2% ropivacaine in 5 mL aliquots.Results Nine hours post-puncture (two hours post-extubation), the patient developed irritability, convulsions, hypertension with bradycardia, and respiratory arrest. He was reintubated and shifted to ICU. CT brain revealed pneumoventricle with air in the frontal horns of the lateral ventricles and basal cisterns. He was managed with intravenous midazolam, mechanical ventilation for 12 hours, and supportive care. The epidural catheter was removed 24 hours post-puncture. He was extubated successfully with full neurological recovery.Abstract OP24 Figure 1Pneumoventricle in the frontal horn of the lateral ventriclesAbstract OP24 Figure 2Pneumoventricle in the basal cisternConclusions Pneumoventricle following epidural dural puncture is a rare but potentially life-threatening complication. Using saline instead of air for LOR may help prevent such occurrences. Anaesthesiologists should maintain a high index of suspicion in atypical presentations and consider early neuroimaging for prompt diagnosis and intervention.