Case Report: Multifocal cerebral infarctions caused by cyanoacrylate glue embolization after gastric variceal injection

Background: Endoscopic injection of N-butyl-2-cyanoacrylate (Histoacryl) is a first-line treatment for bleeding gastric varices. Although generally safe, rare systemic complications including paradoxical cerebral embolization can occur, carrying devastating neurological consequences. Case presentation: We report a 62-year-old man with probable alcohol-related cirrhosis who presented with acute upper gastrointestinal bleeding secondary to gastroesophageal gastric varices and underwent urgent endoscopic cyanoacrylate injection with a total volume of 8 mL, achieving immediate hemostasis. Post-procedure, the patient failed to regain consciousness. Neuroimaging revealed extensive multifocal cerebral embolization with radiopaque glue material involving both anterior and posterior circulation territories, consistent with systemic cyanoacrylate embolization. Transesophageal echocardiography with agitated saline contrast confirmed the absence of a patent foramen ovale or intracardiac right-to-left shunt, supporting an extracardiac mechanism of embolization, most probably via portopulmonary venous anastomoses related to portal hypertension. Despite intensive neurocritical care, the patient developed progressive cerebral edema with herniation and died 48 h later. Conclusion: Cerebral embolization is a rare but catastrophic complication of endoscopic cyanoacrylate injection. This case highlights the role of unrecognized portosystemic collateral pathways in facilitating paradoxical embolization even in the absence of a cardiac shunt. Failure to awaken or acute neurological deterioration post-variceal therapy should prompt immediate neuroimaging. Greater emphasis on pre-procedural imaging, careful injection technique, and risk-reduction strategies is essential.