Massive Ischemic Stroke Due to Pulmonary Barotrauma and Cerebral Artery Air Embolism During Commercial Air Travel

BACKGROUND Air embolism into the systemic arterial circulation secondary to pulmonary barotrauma has rarely been reported. Herein, we report the clinical course of an extremely rare presentation of cerebral air embolism likely due to ruptured pulmonary bullae during commercial air travel. CASE REPORT A 65-year-old man suddenly became unconscious during an airplane descent. Upon landing, he was immediately transferred to the nearest emergency department where he was intubated for airway protection. His head CT angiogram showed multiple air pockets in the right parietal lobe suspicious for multiple air emboli. His chest CT scan showed multiple large bullae in the left upper and lower lobes as well as diffusely emphysematous lung tissue. After initial stabilization, he underwent emergent hyperbaric oxygen treatment (HBOT) in the multiplace chamber at 2.8 atmospheres. The patient tolerated HBOT well with no complications. However, his neurologic status deteriorated in the following 24 hours due to progression of his cerebral edema and mass effects. The patient's clinical status was discussed with his family and the decision was made to withdraw life-sustaining measures. He died shortly after withdrawal of life support. Post-mortem examination confirmed the presence of very large bullae in the lungs bilaterally. CONCLUSIONS Spontaneous cerebral air embolism is a possible complication of ruptured pulmonary bullae during air travel. HBOT is well-tolerated and may be used with caution even in the presence of emphysematous bullae.