Venous air embolism induced by burr hole drilling before dural incision in craniotomy: two case reports

TL;DR

Two patients developed venous air embolism during craniotomy before the dura was cut, showing the need for close monitoring and quick action to prevent serious complications.

Contribution

Reports two rare cases of VAE occurring before dural incision, expanding understanding of its timing and causes in neurosurgery.

Findings

VAE occurred during burr hole drilling before dural incision in both cases.

Intracranial venous air was confirmed via postoperative CT in multiple venous structures.

Prompt intervention and monitoring helped stabilize the patients and prevent fatal outcomes.

Abstract

Venous air embolism (VAE) is a rare but potentially fatal complication in neurosurgery typically caused by injury to dura mater, especially venous sinuses, during craniotomy. We report two cases of VAE that occurred before dural incision.

Both patients underwent craniotomy under general anesthesia in a head-up position. Hemodynamic and respiratory deterioration occurred during or immediately after burr hole drilling with abnormal vital signs and transesophageal echocardiography findings, raising suspicion for VAE. Immediate management, including surgical field protection and cardiopulmonary support, stabilized the patients’ conditions. The procedure was subsequently discontinued in case 1 and modified to limited resection in case 2. Postoperative computed tomography revealed intracranial venous air within the internal jugular vein, cavernous sinus, and diploic veins.

These cases highlight that VAE can occur even before dural incision. Vigilant intraoperative monitoring and prompt intervention are essential for preventing potentially fatal outcomes.

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