Severe cerebral air embolism after CT-guided hook-wire localization - complete recovery and delayed lung resection: A...

Systemic air embolism (SAE) is a rare complication of computed tomography-guided hook-wire localization for lung resection, and no prior cases of severe cerebral SAE with complete recovery followed by successful delayed lung resection have been described. This report highlights the management of a severe SAE case and the approach to delayed surgery in the presence of retained wire.

A 60-year-old man with an 8-mm pure ground-glass nodule in the lingular segment of the left upper lobe developed sudden loss of consciousness and hemoptysis immediately after uncomplicated hook-wire placement.

Head computed tomography revealed multiple intravascular gas collections in the left frontal lobe, confirming acute cerebral SAE. Additional imaging demonstrated evolving cytotoxic edema involving the bilateral fronto-parieto-occipital lobes and cerebellum.

Emergency endotracheal intubation, high-flow normobaric oxygen, sedation, and temperature control (hypothermia) were initiated. Hyperbaric oxygen therapy was not available due to hemodynamic instability and a fresh pulmonary puncture. Intensive neurorehabilitation followed, with close monitoring and gradual imaging over the following 9 days.

The patient experienced marked functional recovery, regaining fine motor skills and independence in daily activities. Fifty-six days post-event, the retained hook-wire was removed during video-assisted thoracoscopic surgery, and successful resection was performed. Histology confirmed minimally invasive adenocarcinoma with negative margins. No perioperative complications occurred, and the patient was discharged on postoperative day 6 without neurological sequelae.

This case highlights the importance of early recognition and management of SAE, the role of neurorehabilitation, and the decision-making regarding retained hook-wire. The use of strict positioning post-puncture and the potential for delayed surgery after significant neurological recovery should be considered. While hyperbaric oxygen therapy remains ideal, rapid high-flow oxygen administration and comprehensive care can lead to favorable outcomes, enabling the safe completion of planned thoracic procedures.