Cerebral air embolism presenting as acute pneumocephalus during hemodialysis via an arteriovenous fistula in a patient with end-stage renal disease: a case report

Hemodialysis is a life-sustaining but procedurally complex intervention. Pneumocephalus, a rare complication of hemodialysis defined as the presence of air within the cranial vault, can range from small asymptomatic collections to life-threatening tension pneumocephalus. We report a case of acute pneumocephalus in a 65-year-old woman undergoing routine hemodialysis for end stage renal disease secondary to polycystic kidney disease. The patient collapsed within minutes of initiating dialysis with sudden alteration of consciousness. Emergency non-contrast brain CT revealed pneumocephalus. She was intubated, positioned in left Trendelenburg, and received supportive care, including resumption of hemodialysis via central venous access. Follow-up imaging showed resolution of intracranial air with residual ischemic changes in the right hemisphere. She was extubated after 14 days, with residual left hemiplegia, and transferred to the general ward. This case highlights a rare but potentially serious complication of hemodialysis and emphasizes the importance of early recognition, prompt management, and preventive strategies.