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The inadvertent intracranial introduction of nasogastric tube: The lesson learned the hard way

Misdirection of nasogastric tube (NGT) into the cranial cavity is a well-documented complication, usually seen in patients with fracture of skull base. However, there are very few nontrauma cases have been described in the literature with this complication in nontrauma cases. Approximately 39 cases of inadvertent insertion of NGT into the cranial cavity have been reported in the literature. We are reporting accidental malpositioning of NGT into the brain of an elderly lady who was admitted with medical illness. Her computed axial tomography scan of the head showed the intracranial placement of tube. The NGT was retrieved, but after 48 h of tube insertion, the patient expired. The aim to present this rare case is to create awareness about this potential and dreaded complication associated with NGT intubation.