Cerebral Air Embolism after Small-bore Chest Tube Insertion in a Patient with Hydropneumothorax: A Case Report

Cerebral air embolism (CAE) is a rare but potentially fatal complication, characterized by the entry of air bubbles into the arterial circulation, subsequently obstructing cerebral blood flow and causing ischemic injury. While CAE is a recognized risk in cardiovascular surgery, barotrauma, trauma of the chest or head, it remains an extremely rare complication of pleural procedures, which is even more exceptional when occurring during chest tube placement. To our knowledge, we report the first case of CAE induced by insertion of a small-bore (12 Fr) chest tube via a safety Verres needle technique in a patient with hydropneumothorax.

The patient was admitted with cough, confusion, fever, and dyspnea. Diagnostic imaging, including a chest x-ray (CXR) and chest Computed Tomography (CT), detected a rightsided hydropneumothorax, which was also identified by thoracic ultrasound. During the 12 Fr chest tube insertion with the patient in the supine position, a sudden loss of consciousness and convulsions occurred. The patient was administered the Trendelenburg position and high-flow oxygen therapy, recovering consciousness within minutes, with residual neurologic deficits. A subsequent head CT scan revealed CAE.

This case highlights an exceptionally rare but potentially devastating complication of pleural drainage insertion, underscoring the need for heightened clinical vigilance during all pleural procedures, regardless of procedural complexity or drainage size. Although thoracic ultrasound is fundamental for guiding chest tube placement, a thickened pleura is associated with increased procedural risk due to increased resistance. Clinicians should promptly recognize acute neurological deterioration during chest tube placement as a possible manifestation of CAE, performing an early neuroimaging and immediate management.