A 72-year-old woman with chronic cough due to severe interstitial lung disease and fibrosis was found in a coma upon awakening. Glasgow Coma Scale score: 3. Gaze deviation to the left. Generalized hypotonia. Anisocoric pupils with right-sided mydriasis. Thoracic CT scan: small left apical pneumothorax and presence of ectopic air in the upper mediastinum (arrows) (Fig. 1). Brain CT scan: presence of numerous air bubbles located in the cerebral sulci (arrows), and cortico-subcortical hypodense areas distributed in bilateral parieto-occipital regions (Fig. 2). An intrapulmonary shunt would be mechanism involved that could explain our case (for the lack of a patent foramen ovale). A sudden increase of intrathoracic pressure due to Valsalva maneuvers, along with the development of pneumothorax and pneumomediastinum in a pathological lung could facilitate the passage of air into the pulmonary veins and from there into the left circulatory system causing cerebral air embolisms.

Figure 1

Figure 2