Venous air embolism in neurosurgery

  • Mauricio Giraldo Clinical Fellow Cardiac Anesthesia, Department of Anesthesia and Perioperative Medicine LHSC, Western University, London, Ontario, Canada
  • Luz María Lopera Regional Anesthesia Department, Department of Anesthesia and Perioperative Medicine LHSC, Western University, London, Ontario, Canada
  • Miguel Arango Department Neuroanesthesia, Department of Anesthesia and Perioperative Medicine LHSC, Western University, London, Ontario, Canada
Keywords: Neurosurgery, Neurosurgical, procedures, Embolism, air, Anesthesia, Cerebral, veins


Venous air embolism is a potentially serious neurosurgical complication. Every neurosurgical procedure is at risk of developing the condition but the sitting and semi-sitting position represent a higher risk. The neuroanesthesiologist plays a key role in the management of the venous air embolism, from diagnosis to treatment. This article reviews the literature on air embolism in terms of its incidence, etiology, diagnosis and therapy.


1. Ganslandt O, Merkel A, Schmitt H, Tzabazis A, Buchfelder M, Eyupoglu I, et al. The sitting position in neurosurgery: indications, complications and results. a single institution experience of 600 cases. Acta Neurochir (Wien). 2013;155:1887-93.

2. Tobias JD, Johnson JO, Jimenez DF, Barone CM, McBride DS. Venous air embolism during endoscopic strip craniectomy for repair of craniosynostosis in infants. Anesthesiology. 2001;95:340-2.

3. Wei S-T, Chen D-C. Catastrophic venous air embolism during craniotomy in the supine position: the bleeding pattern as a warning sign? J Craniofac Surg. 2013;24:e228-9.

4. Israelian L, Shimanskii V, Otamanov D, Poshataev V, Lubnin A. Patient positioning on the operating table in neurosurgery: sitting or lying. Anesteziol Reanimatol. 2013:18-26.

5. Chang EF, Cheng JS, Richardson RM, Lee C, Starr PA, Larson PS. Incidence and management of venous air embolisms during awake deep brain stimulation surgery in a large clinical series. Stereotact Funct Neurosurg. 2011;89:76-82.

6. Ammirati M, Lamki TT, Shaw AB, Forde B, Nakano I, Mani M. A streamlined protocol for the use of the semi-sitting position in neurosurgery: a report on 48 consecutive procedures. J Clin Neurosci. 2013;20:1-6.

7. Young ML, Smith DS, Murtagh F, Vasquez A, Levitt J. Comparison of surgical and anesthetic complications in neurosurgical patients experiencing venous air embolism in the sitting position. Neurosurgery. 1986:157-61.

8. Vinay B, Sriganesh K, Gopala Krishna KN. An abrupt reduction in end-tidal carbon-dioxide during neurosurgery is not always due to venous air embolism: a capnograph artefact. J Clin Monit Comput. 2013;31:5-7.

9. Mirski MA, Lele AV, Fitzsimmons L, Toung TJK. Diagnosis and treatment of vascular air embolism. Anesthesiology. 2007;106:164-77.

10. Felema GG, Bryskin RB, Heger IM, Saswata R. Venous air embolism from Tisseel use during endoscopic cranial vault remodeling for craniosynostosis repair: a case report. Paediatr Anaesth. 2013;23:754-6 [cited 14.04.14]

11. Harrison EA, Mackersie A, McEwan A, Facer E. The sitting position for neurosurgery in children: a review of 16 years' experience. Br J Anaesth. 2002;88:12-7.

12. Aleksic V, Radulovic D, Milakovic B, Nagulic M, Vucovic D, Antunovic V, et al. A retrospective analysis of anesthesiologic complications in pediatric neurosurgery. Paediatr Anaesth. 2009;19:879-86.

13. Singh G, Prabhakar H, Bithal P, Dash H. A retrospective analysis of perioperative complications during intracranial neuroendoscopic procedures: our institutional experience. Ann Indian Acad Neurol. 2011;59:465-6.

14. Mertens C, Schmitt H, Tzabazis A. Advantages of the Sitting Position in a Case of Severe COPD. J Neurosurg Anesth. 2013;25:93-4.

15. Pahnon SC, Toung T. Special Article SP Venous Air Embolism: A Review. 1997;8180:97.

16. Paladino MA. Eventos intraoperatorios en neurocirugía. Rev Arg Anest. 2004;62:133-51.

17. Toung TJ, Rossberg MI, Hutchins GM. Volume of air in a lethal venous air embolism. Anesthesiology. 2001:360-1.

18. Van Hulst RA, Klein J, Lachmann B. Gas embolism: pathophysiology and treatment. Clin Physiol Funct Imaging. 2003;23:237-46.

19. Warner DS, Embolism A, Maurice B, Carroll RG. Abstract. Monogr Soc Res Child Dev. 2013;78:vii.

20. Hassan WMNW, Zainuddin A, Ali S. Venous air embolism during elective craniotomy for parasagittal meningioma. Med J Malaysia. 2013;68:69-70.

21. Ingelmo I, Fabregas N, Rama-Maceiras P, Rubio R, Badenes R, Valencia L, et al. Encuesta sobre el tratamiento anestesiológico de los pacientes sometidos a neurocirugía de fosa posterior Questionnaire on the Anaesthesiology Treatment of Patients Subjected to Posterior Fossa Neurosurgery. Rev Esp Anestesiol Reanim. 2012;59:118-26.

22. Misra BK. Neurosurgery in the semisitting position in patients with a Patent Foramen Ovale. World Neurosurg. 2013;3:7-8. Elsevier Inc.

23. Faberowski LW, Black S, Mickle JP. Incidence of venous air embolism during craniectomy for craniosynostosis repair. Anesthesiology. 2000;92:20-3.

24. Hooper AK, Okun MS, Foote KD, Haq IU, Fernandez HH, Hegland D, et al. Venous air embolism in deep brain stimulation. Stereotact Funct Neurosurg. 2009;87:25-30.

25. Ooba H, Abe T, Momii Y, Fujiki M. Venous air embolism (VAE) associated with stereotactic biopsies. Acta Neurochir (Wien). 2013.

26. Bithal PK, Pandia MP, Dash HH, Chouhan RS, Mohanty B, Padhy N. Comparative incidence of venous air embolism and associated hypotension in adults and children operated for neurosurgery in the sitting position. Eur J Anaesthesiol. 2004;21:517-22.

27. Moningi S, Kulkarni D, Bhattacharjee S. Coagulopathy following venous air embolism: a disastrous consequence - a case report. Kor J Anesthesiol. 2013;65:349-52.

28. Kumar R, Goyal V, Chauhan RS. Venous air embolism during microelectrode recording in deep brain stimulation surgery in an awake supine patient. Br J Neurosurg. 2009;23:446-8.

29. Furtado SV, Venkatesh PK, Murthy GK, Furtado AD, Hegde AS. Paradoxical embolus across atrial septal defect and posterior circulation infarct in neurosurgical patients. Int J Neurosci. 2010;120:516-20.

30. Arora R, Chablani D, Rath GP, Prabhakar H. Pulmonary oedema following venous air embolism during transsphenoidal pituitary surgery. Acta Neurochir (Wien). 2007;149:1177-8.

31. El-Zenati H, Faraj J, Al-Rumaihi GI. Air embolism related to removal of Mayfield head pins. Asian J Neurosurg. 2012;7:227-8.

32. Schäfer ST, Sandalcioglu IE, Stegen B, Neumann a, Asgari S, Peters J. Venous air embolism during semi-sitting craniotomy evokes thrombocytopenia. Anaesthesia. 2011;66:25-30.

33. Duda I, Grzybowska K, Jedrzejowska-Szypulka H, Lewin-Kowalik J. The sitting position during neurosurgical procedures does not influence serum biomarkers of pulmonary parenchymal injury. BMC Surg. 2012;12:24.

34. Schubert A, Deogaonkar A, Drummond JC. Precordial Doppler probe placement for optimal detection of venous air embolism during craniotomy. Anesth Analg. 2006;102:1543-7.

35. Feigl GC, Decker K, Wurms M, Krischek B, Ritz R, Unertl K, et al. Neurosurgical procedures in the semisitting position: evaluation of the risk of paradoxical venous air embolism in patients with a Patent Foramen Ovale. World Neurosurg. 2013:1-6. Elsevier Inc.

36. Nozaki K. Selection of semisitting position in neurosurgery: essential or preference? World Neurosurg. 2014;81:62-3. Elsevier Inc.

37. Shaikh N, Ummunisa F. Acute management of vascular air embolism. J Emerg Trauma Shock. 2009;2:180-5.

38. Schlundt J, Tzanova I, Werner C. A case of intrapulmonary transmission of air while transitioning a patient from a sitting to a supine position after venous air embolism during a craniotomy. Can J Anaesth. 2012;59:478-82.

39. Fathi A-R, Eshtehardi P, Meier B. Patent foramen ovale and neurosurgery in sitting position: a systematic review. Br J Anaesth. 2009;102:588-96.

40. Pandia MP, Bithal PK, Dash HH, Chaturvedi A. Comparative incidence of cardiovascular changes during venous air embolism as detected by transesophageal echocardiography alone or in combination with end tidal carbon dioxide tension monitoring. J Clin Neurosci. 2011;18:1206-9. Elsevier Ltd.

41. Wong AY, Irwin MG. Large venous air embolism in the sitting position despite monitoring with transoesophageal echocardiography. Anaesthesia. 2005;60:811-3.

42. Stendel R, Gramm HJ, Schröder K, Lober C, Brock M. Transcranial Doppler ultrasonography as a screening technique for detection of a patent foramen ovale before surgery in the sitting position. Anesthesiology. 2000;93: 971-5.

43. Hervias A, Valero R, Hurtado P, Gracia I, Perelló L, Tercero F, et al. Detection of venous air embolism and patent foramen ovale in neurosurgery patients in sitting position. Neurocirugia. 2014;14,

44. Albin M. Venous air embolism: a warning not to be complacent - we should listen to the drumbeat of history. Anesthesiology. 2011;115:626-9.

45. Pasternak JJ, Lanier WL. Is nitrous oxide use appropriate in neurosurgical and neurologically at-risk patients? Curr Opin Anaesthesiol. 2010;23:544-50.

46. Aragonés Manzanares R, Cabello Roig B, Medina Arteaga A, Muñoz Lopez A, Seller Perez G. M DA. Edema pulmonar agudo tras embolismo aéreo venoso central. Med Intensiva. 2002;26:127-31.

47. Adornato DC, Gildenberg PL, Ferrario CM, Smart J, Frost Ea. Pathophysiology of intravenous air embolism in dogs. Anesthesiology. 1978;49:120-7.

48. Basaldella L, Ortolani V, Corbanese U, Sorbara C, Longatti P. Massive venous air embolism in the semi-sitting position during surgery for a cervical spinal cord tumor: anatomic and surgical pitfalls. J Clin Neurosci. 2009;16:972-5. Elsevier Ltd.

49. Kjeld T, Hansen EG, Holler NG, Rottensten H, Hyldegaard O, Jansen EC. Resuscitation by hyperbaric exposure from a venous gas emboli following laparoscopic surgery. Scand J Trauma Resusc Emerg Med. 2012;20:51.

50. Pandia MP, Bithal PK, Sharma MS, Bhagat H, Prasanna B. Use of spontaneous ventilation to monitor the effects of posterior fossa surgery in the sitting position. J Clin Neurosci. 2009;16:968-9. Elsevier Ltd.
How to Cite
Giraldo M, Lopera LM, Arango M. Venous air embolism in neurosurgery. Colomb. J. Anesthesiol. [Internet]. 2015Jul.1 [cited 2021Jun.24];43(Supplement):40-4. Available from:


Download data is not yet available.
How to Cite
Giraldo M, Lopera LM, Arango M. Venous air embolism in neurosurgery. Colomb. J. Anesthesiol. [Internet]. 2015Jul.1 [cited 2021Jun.24];43(Supplement):40-4. Available from:

More on this topic