Air embolism to the brain: critical management advice for the neurologist

Neurological conditions associated with air entry into the systemic circulation are rare, particularly when compared with other particles. Patients present with an acute decline in the level of consciousness and new focal neurological deficits, often including new hemiparesis. A single seizure may also be a heralding sign. Patients may progress to deep coma. The first line of action, before anything else, is (1) the immediate positioning of the patient in Trendelenburg and in left lateral decubitus; (2) giving oxygen using a closed face mask (10-15 L/min) or high-flow nasal cannulae (up to 60 L/min). We recommend hyperbaric oxygen therapy if facilities can be reached within an 8-hour window. Awakening from coma, improvement of hemiparesis and good functional outcome may occur, but progress is likely to be slow and protracted. The emphasis of this review is on the recognition, immediate and subsequent treatment of air embolism to the brain.