Cerebral air embolism from oesophageal-pulmonary vein fistula induced by fish bone ingestion.

Fish bone ingestion caused an oesophageal-pulmonary vein fistula resulting in cerebral air embolism, a rare complication.

• The patient was a man in his 80s who presented after sudden collapse following oesophageal discomfort from fish bone ingestion the previous day.
• The case was managed at a tertiary emergency centre.
• Cerebral air embolism as a secondary complication of fish bone ingestion is described as 'exceedingly rare'.

Head CT identified punctate hypodense foci in the right frontal white matter consistent with cerebral air.

• CT perfusion showed decreased cerebral blood flow with delayed transit time in the affected region.
• These findings were identified on initial presentation imaging.
• Multimodal imaging including both non-contrast CT and CT perfusion contributed to the diagnosis.

Chest CT demonstrated a fish bone impacted in the distal oesophagus with air bubbles visible in the pulmonary vein.

• The presence of air bubbles in the pulmonary vein on chest CT provided evidence of the oesophageal-pulmonary vein fistula.
• The fish bone was located in the distal oesophagus.
• This imaging finding linked the oesophageal perforation to the cerebral air embolism via systemic arterial air entry.

Urgent endoscopy confirmed the fish bone, which was removed under general anaesthesia with mucosal clipping performed for haemostasis.

• General anaesthesia was used for procedural safety during fish bone removal.
• Mucosal clipping was employed as the haemostatic technique following fish bone extraction.
• The procedural approach reflects considerations for safe management in the context of concurrent cerebral air embolism.

MRI performed on day six demonstrated cortical infarctions in the right hemisphere.

• The infarctions were identified six days after the initial presentation.
• Infarctions were located in the cortex of the right hemisphere, consistent with the initial CT findings of right frontal involvement.
• The MRI findings confirmed ischaemic injury resulting from the cerebral air embolism.

The case underscores the diagnostic importance of multimodal imaging for cerebral air embolism caused by oesophageal perforation.

• Modalities used included head CT, CT perfusion, chest CT, and MRI.
• The combination of imaging modalities allowed identification of both the source (oesophageal fistula) and the consequence (cerebral air embolism and subsequent infarction).
• The authors highlight procedural planning as essential for safe management in this rare complication.