Tension pneumocephalus (TPC) is a rare but devastating intracranial condition where increased intracranial pressure due to entrapped air causes compression of the brain leading to headache, seizures, altered mental status (AMS), and death. The author presents the case of patient with a past medical history of eye-enucleation who subsequently developed TPC in the setting of occult trauma. The diagnosis was made via commuted tomography (CT) scan and the patient underwent needle and burr-hole decompression in the emergency department (ED). TPC is a rare cause of altered mental status, which occurs most often secondary to trauma, and should be considered in patients with AMS and trauma.