Intraoperative venous air embolism during endoscopic transsphenoidal surgery: recommendations for management. Illustrative case.

Background: Venous air embolism (VAE) is a rare neurosurgical complication that occurs when air is trapped in a large, exposed vein and there is a pressure gradient that drives the air embolus from the surgical site to the right heart. This case highlights the identification and management of intraoperative VAE during transsphenoidal surgery. Additional discussion is provided on pathophysiology and best practices for reducing risk of occurrence.

Observations: A 53-year-old female presented with several days of severe headaches and acute visual loss. Initial workup revealed a hemorrhagic suprasellar mass with optic chiasm compression and panhypopituitarism. The patient was taken for endoscopic transsphenoidal resection of the mass and optic chiasm decompression. Intraoperatively, the patient experienced several episodes of hypotension and decreased end-tidal CO2. Her vitals stabilized following Trendelenburg repositioning. The operation was halted following optic chiasm decompression. The patient's postoperative course was notable for cerebral vasospasm, CSF leakage, and hypovolemic shock, requiring savvy multidisciplinary management. The patient was discharged with improvement of baseline vision and no focal neurological deficits.

Lessons: VAE occurs rarely during transsphenoidal surgery. Prompt recognition, clear communication, and rapid intervention reduce the chance of morbidity from VAE intraoperatively and might allow for continuation of the procedure. https://thejns.org/doi/10.3171/CASE24691.