Cerebral Air Embolism After Gastrointestinal Procedure: A Case Report and Literature Review

Abstract

Esophagogastroduodenoscopy (EGD) is one of the forefronts of minimally invasive modalities with excellent safety records and tremendous capability but despite its accolades and functions, there are still very rare complications including air embolism. It is a life-threatening condition that could lead to a significant increase in morbidity and mortality. However, there are limited data for incidence of air embolism in association with gastrointestinal endoscopy. Diagnosis of air embolism after or during gastrointestinal endoscopy might be a difficult task due to overlapping presentations with anesthesia effects on the cardiopulmonary and the neurological systems, as a result, there should be increased awareness allowing clinicians to quickly rule out air embolism in patient with altered mental status or cardiopulmonary changes after or during gastrointestinal endoscopy. Herein, we report a unique case of cerebral air embolism after EGD in a 79-year-old female patient. In addition, we also performed a systematic review of cases based on PRISMA guideline, with the aim to investigate the demographics and clinical outcomes associated with this complication. This systematic review of cases hopes to increase the awareness about this rare entity.

Cerebral Air Embolism After Endoscopy: A Case Report

“… 6 , 7 In total there appear to be only 13 reported cases of CAE after EGD, reinforcing its rarity. 8 …”

“…6,7 In total there appear to be only 13 reported cases of CAE after EGD, reinforcing its rarity. 8 There are a variety of proposed mechanisms by which gas can enter vasculature during endoscopy including through the portal vein, exposed gastrointestinal vessels, or through adjacent veins of inflamed mucosa. 2 Theories on how air reaches the arterial system, and specifically the central nervous system, include paradoxical embolization through heart shunts such as a patent foramen ovale, retrograde flow through the superior vena cava, and through pulmonary veins if not filtered by the pulmonary system.…”

Diffuse Bi-hemispheric Cortical Infarction Secondary to Cerebral Air Embolism After Elective Esophagogastroduodenoscopy: A Case Report and Review of Literature

“…Air may enter directly through exposed vessels within gastric ulcers or gastric tumors. The higher-pressure gradients secondary to the insufflation of air during the procedure are further hypothesized to facilitate air entry [ 5 , 6 ]. Translocation of air from the venous circulation to the systemic circulation can be secondary to intracardiac shunts like PFO.…”

“…Recent studies have shown that early identification and early initiation of HBO therapy result in improved outcomes in CAE patients. HBO is believed to help by decreasing the size of gas emboli and providing higher oxygen concentrations in arterial blood which may benefit the ischemic tissue [ 1 , 2 , 4 , 6 ]. Initiating HBO therapy more than six hours after insult, as well as early and significant ischemic changes seen on CT/MRI before starting therapy were both considered strong predictors of poor neurological and clinical outcomes [ 1 , 2 , 4 ].…”

“…Initiating HBO therapy more than six hours after insult, as well as early and significant ischemic changes seen on CT/MRI before starting therapy were both considered strong predictors of poor neurological and clinical outcomes [ 1 , 2 , 4 ]. Unfortunately, a significant portion of patients is under sedation for the procedure, often resulting in delays in clinical diagnosis and initiating treatment, further resulting in poor outcomes [ 6 , 8 ].…”