Intraparenchymal hemorrhage related to cerebral venous air embolism secondary to mesenteric ischemia

INTRODUCTION The presence of air in vascular structures of the brain can lead to neurological symptoms and significant morbidity. It usually occurs as a consequence of invasive therapeutic procedures and is very rarely triggered by any other cause. CASE REPORT We report the case of a 76-year-old woman with a history of atrial fibrillation anticoagulated with acenocoumarol who visited the Emergency department because of sudden-onset abdominal pain, vomiting and diarrhoea. After starting symptomatic treatment and finding analytical evidence of underdosing of the anticoagulant, she suddenly presented with neurological focus. A cranial computed tomography scan revealed an acute intraparenchymal haemorrhage. The patient was transferred to the stroke unit of the referral hospital. Within a few hours, she developed haemodynamic instability due to a septic shock that had its origin in the abdomen. A computed tomography scan of the abdomen evidenced extensive pneumatosis intestinalis and an obstruction of contrast indicating mesenteric ischaemia. A mechanical thrombectomy was performed in an attempt to embolise the thrombus at a more distal level, but the patient died. CONCLUSIONS Mesenteric ischaemia can cause significant pneumatosis intestinalis, which, by a retrograde mechanism through the portal system, can cause air bubbles to reach the cerebral venous system, leading to acute stroke.