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A 61 year old right-handed Caucasian male with a history of CKD4, hypertension, protein C deficiency with prior PE/DVTs on apixiban presented with acute left sided weakness. The patient was recently diagnosed with ESRD and learning home hemodialysis. While undergoing teaching at dialysis, the patient coughed and the catheter cap was not completely closed, introducing air inline and the line uncapped briefly until nursing recapped the catheter. The patient became acutely symptomatic with shortness of breath and left hemibody weakness.

Initial imaging on arrival to the hospital showed cerebral air embolism with right MCA/ACA watershed ischemia and patient was placed in supine position. Repeat CTA head approximately 14 hours later showed resolution of air emboli, but new high convexity edema. MRI confirmed edema in the right frontal region with diffusion restriction in a sulcal pattern. The patient was treated with hyperosmolar therapy to correct hyponatremia. He also had subjective dyspnea, and nonrebreather was used. He developed near continuous myoclonus in the left lower extremity without EEG evidence of cortical myoclonus, which resolved with clonazepam. Patient also developed right pulmonary artery thrombus requiring anticoagulation, initially with heparin and discharged with apixaban.