Shiva Priya K, Kaushal A, Lokho P, Balasubramanian N, Agrawal A, Kant S, Badetiya N. Seizure-associated venous air embolism during awake craniotomy in the supine position: A case report. World J Clin Cases 2026; 14(9): 119273 [DOI: 10.12998/wjcc.v14.i9.119273]
Corresponding Author of This Article
Ashutosh Kaushal, DM, MD, DNB, Additional Professor, Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462026, Madhya Pradesh, India. drashutosh.kaushal@gmail.com
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Anesthesiology
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Case Report
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Mar 26, 2026 (publication date) through Mar 27, 2026
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Publication Name
World Journal of Clinical Cases
ISSN
2307-8960
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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
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Shiva Priya K, Kaushal A, Lokho P, Balasubramanian N, Agrawal A, Kant S, Badetiya N. Seizure-associated venous air embolism during awake craniotomy in the supine position: A case report. World J Clin Cases 2026; 14(9): 119273 [DOI: 10.12998/wjcc.v14.i9.119273]
Kandukuri Shiva Priya, Neuroanesthesiology and Neurocritical Care, All India Institute of Medical Sciences, Delhi 110029, Delhi, India
Ashutosh Kaushal, Pfokreni Lokho, Niranjani Balasubramanian, Surya Kant, Nikhil Badetiya, Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal 462026, Madhya Pradesh, India
Amit Agrawal, Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal 462026, Madhya Pradesh, India
Co-first authors: Kandukuri Shiva Priya and Ashutosh Kaushal.
Author contributions: Shiva Priya K and Kaushal A are co-first authors and contributed equally to this work; Shiva Priya K and Kaushal A made the most significant intellectual contributions, including conceptualization, acquiring and analyzing data, and drafting the original manuscript; Shiva Priya K, Kaushal A, Lokho P, Balasubramanian N, Agrawal A, Kant S, and Badetiya N collected and analyzed the data; Kaushal A and Agrawal A supervised the report; The original manuscript was prepared by Shiva Priya K and Kaushal A, and it was critically reviewed and edited by Agrawal A, Balasubramanian N, and Lokho P; and all authors have read and approved the final version of the manuscript.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Corresponding author: Ashutosh Kaushal, DM, MD, DNB, Additional Professor, Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Saket Nagar, Bhopal 462026, Madhya Pradesh, India. drashutosh.kaushal@gmail.com
Received: January 28, 2026 Revised: February 14, 2026 Accepted: March 5, 2026 Published online: March 26, 2026 Processing time: 55 Days and 16.1 Hours
Abstract
BACKGROUND
Venous air embolism (VAE) is a recognized complication of neurosurgical procedures, particularly in the sitting position, but may occur in any position where the surgical field is above the level of the heart. Its occurrence during awake craniotomy in the supine position is rare and diagnostically challenging due to limited monitoring and nonspecific clinical manifestations.
CASE SUMMARY
We report the case of a 22-year-old male undergoing awake craniotomy in supine position for resection of a right fronto-temporal low-grade glioma, identified on preoperative magnetic resonance imaging as a non-enhancing cortical lesion in close proximity to eloquent motor cortex, with functional magnetic resonance imaging demonstrating perilesional motor and supplementary motor area activation. Near the completion of tumor excision, the patient developed non-convulsive seizure activity followed by persistent coughing, dyspnea, chest tightness, tachypnoea, tachycardia, and hypoxemia. A new continuous precordial murmur was detected. VAE was suspected based on clinical findings. Immediate management included flooding the surgical field with saline, Trendelenburg positioning, administration of 100% oxygen with positive end-expiratory pressure, and supportive care. The patient improved rapidly, with normalization of oxygen saturation and vital parameters. Post-event transthoracic echocardiography revealed no cardiac dysfunction, while lung ultrasound demonstrated bilateral B-lines, consistent with pulmonary interstitial involvement.
CONCLUSION
VAE can occur during awake craniotomy even in the supine position, potentially precipitated by seizure-related deep inspiratory efforts. Given the nonspecific presentation and diagnostic limitations in awake neurosurgery, a high index of suspicion and prompt supportive management are essential to ensure favourable outcomes.
Core Tip: Venous air embolism (VAE), though classically associated with neurosurgical procedures in the sitting position, can also occur during awake craniotomy in the supine position and may present with subtle, nonspecific symptoms. In awake patients, seizure-related deep inspiratory efforts and transient negative intrathoracic pressure can facilitate air entrainment through exposed cerebral veins, particularly when the surgical field is positioned above the level of the heart. Overlap between seizure activity and the clinical manifestations of VAE can delay recognition in the absence of advanced monitoring. This case highlights the need for heightened vigilance, early clinical suspicion, and prompt supportive management to ensure favorable outcomes during awake craniotomy.
