Rapid buildup of gas within the cranial vault can result in a life-threatening condition known as "tension pneumocephalus," necessitating immediate surgical intervention. Nitrous oxide (N2O), a commonly used inhaled anesthetic, is associated with the development of tension pneumocephalus and its role in neurosurgical procedures has been debated in the literature. We present a case of tension pneumocephalus with preexisting pneumocephalus secondary to the usage of N2O as an inhaled anesthetic. Included is a literature review of studies discussing the role of N2O in the development of tension pneumocephalus. N2O is associated with tension pneumocephalus especially in the setting of preexisting pneumocephalus. Tension pneumocephalus can manifest as Cushing response and immediate decompression is life-saving. Nitrous oxide should be used cautiously in neurosurgical procedures, especially with preexisting pneumocephalus.