Post-mortem CT detection of fatal air embolism after aerosolized fibrin glue for bladder bleeding

Radiation-induced hemorrhagic cystitis (RHC) is a severe complication of pelvic radiotherapy, often used to treat various pelvic malignancies. Despite multiple therapeutic options, including conservative and invasive interventions, the optimal management remains uncertain. We report the case of a 76-year-old male with pulmonary emphysema and a history of prostate cancer treated with radiotherapy, who developed refractory RHC. During a hemostatic transurethral resection of a bladder tumor, autologous fibrin glue was applied via aerosol. Shortly after, the patient experienced sudden cardiorespiratory arrest and died. Post-mortem computed tomography (PMCT) revealed extensive intravascular gas in the heart and cerebral vessels, confirming fatal air embolism. No gas was identified in the pulmonary arteries, and autopsy findings excluded structural cardiac anomalies such as a patent foramen ovale. These results support the hypothesis of a right-to-left functional pulmonary shunt, a mechanism in which venous gas bypasses the pulmonary filter through intrapulmonary arteriovenous anastomoses. Pulmonary emphysema, present in this case, may have contributed by impairing alveolar-capillary integrity and reducing vascular filtration capacity. Additionally, bladder adhesions observed at autopsy likely reduced bladder compliance, facilitating air entry during glue application. This is, to our knowledge, the first documented case of fatal air embolism following aerosolized fibrin glue use for RHC, confirmed by both PMCT and autopsy. The case highlights the need for caution when using aerosolized hemostatic agents in patients with predisposing factors such as bladder adhesions and obstructive pulmonary diseases. Furthermore, it demonstrates the essential role of PMCT in identifying embolic complications and determining the cause of death in forensic settings.