Fish bone ingestion is common, but cerebral air embolism as a secondary complication is exceedingly rare. A man in his 80s presented to our tertiary emergency centre after sudden collapse following oesophageal discomfort from fish bone ingestion the previous day. Head CT revealed punctate hypodense foci in the right frontal white matter, consistent with cerebral air, while CT perfusion showed decreased cerebral blood flow with delayed transit time. Chest CT demonstrated an impacted fish bone in the distal oesophagus and air bubbles in the pulmonary vein. Urgent endoscopy confirmed the fish bone, which was removed under general anaesthesia with mucosal clipping for haemostasis. MRI on day six showed cortical infarctions in the right hemisphere. This case underscores the diagnostic importance of multimodal imaging and procedural planning for the safe management of cerebral air embolism caused by oesophageal perforation.