Fatal Cerebral Air Embolism Following Central Venous Catheter Mishandling in a Stroke Patient: A Case Report

Air embolism is a rare but potentially fatal complication associated with central venous catheter (CVC) use even several days after placement. Although often asymptomatic, large or rapidly introduced volumes of air can result in severe neurologic and cardiovascular compromise.

We report a case of fatal cerebral air embolism in a male stroke patient in his early 60s with a history of diabetes, nephropathy, and peritoneal dialysis. Following ischemic stroke, a CVC was inserted for hemodialysis. Seventeen days after stroke onset, the patient was found unconscious, with seizures and signs of acute neurologic deterioration. The hemodialysis catheter was discovered unplugged and unclamped, suggesting accidental or intentional self-manipulation. Imaging confirmed a massive air embolism in both arterial and venous cerebral circulations. Despite immediate intervention, the patient remained unconscious and died 5 days later. Autopsy confirmed the diagnosis and excluded cardiac or pulmonary shunts.

This case highlights the fatal potential of air embolism following CVC mishandling. Prevention requires meticulous catheter management, staff training, and informing patients about risks.