Cerebral Gas Embolism Caused by Pleural Fibrinolytic Treatment

Abstract

Background and Purpose-Intrapleural fibrinolytic therapy is a technique used to treat empyemas and parapneumonic effusions. Cerebral air embolism is an unusual potentially severe complication of this technique. Summary of Case-A patient with parapneumonic pleural effusion underwent pleural lavage with streptokinase when he suddenly demonstrated focal neurological signs and seizures. The CT revealed multiple air-isodense spots in right hemisphere of the brain, suggesting cerebral air embolism. As a result of early diagnosis and emergency hyperbaric oxygenation, the patient recovered without delayed sequelae. Conclusions-Air embolism is a potentially severe complication which can occur during fibrinolytic pleural lavage, and clinicians should be aware of this risk. In this context, the onset of acute focal neurological signs or seizures should suggest the possibility of air embolism and lead to the transfer of the patient close to a hyperbaric facility within a few hours. (Stroke. 2007;38:2602-2604.)Key Words: air embolism Ⅲ fibrinolytic therapy Ⅲ hyperbaric oxygenation Ⅲ stroke P arapneumonic effusions and empyema may complicate lower respiratory tract infections. In this condition, loculation of fluid is a major problem, and therapeutic options include conventional surgical drainage, video-assisted thoracoscopic surgery and the use of intrapleural fibrinolytic agents (urokinase and streptokinase) to break down fibrin bands that may cause loculation. 1-4 Although many physicians use fibrinolytic agents, the technique of instillation has not yet been standardized. 5 A Cochrane Systematic Review 6 evaluated the benefit of adding intrapleural fibrinolytic therapy to intercostal tube drainage in the treatment of complicated parapneumonic effusions and empyema. Controlled trials conducted up to 2003 were reviewed, concluding that intrapleural fibrinolytic therapy conferred significant benefits when compared with normal saline control. However, the routine use of fibrinolytic therapy cannot be recommended because the trial numbers were too small. A recent meta-analysis raised the same conclusions. 7 Remarkably, complications attributable to therapy were not observed at all in these trials, although several case reports of cerebral air embolism have been published. 8 -10 Herein we report a new case. Case ReportsA 50-year-old male patient, with a previous history of intestinal adenocarcinoma and resection of colorectal liver metastases developed a right purulent pleural effusion (Figure, A). He was admitted to hospital for daily pleural lavages with saline associated with streptokinase and for antibiotic treatment. During the third lavage he suddenly developed a generalized tonic-clonic seizure. Neurological examination showed a drowsy patient, with a conjugated gaze deviation toward the right, lower left facial paralysis, left hemiplegia and left Babinski sign. He immediately underwent a CT scan of the brain which revealed multiple air-isodense spots in the right hemisphere suggesting cerebral air embolisms (Figure, B)....

Nonthrombotic pulmonary embolism

“…The incidences during diagnostic cardiac catheterisation and percutaneous coronary intervention are 0.84% and 0.24%, respectively [254]. AE is a rare complication of ventricular assist device pump dissection [255], ventilation-induced lung trauma [256] and laparoscopy which can lead to air, argon or carbon dioxide embolism [257,258], Other causes include fibrinolytic pleural lavage [259], the intraoperative use of hydrogen peroxide, insufflation of air during endoscopy, laser therapy, arthroscopy, thoracotomy, noninvasive ventilation, carotid endarteriectomy or prostatectomy [245,260].…”

Intrapleural Fibrinolytic Treatment: Management of 85 Cases

“…These complications usually rear within the first two hours of the application and can be easily controlled with antipyretic, analgesic, and O2 treatment. However, other studies have also reported other major postfibrinolytic therapy complications like massive bleeding, allergic reactions, respiratory failure, and cerebral air embolism (8,10,11,12). In their 237-patient series, Abu Daft et al have stated that 15 patients developed pleural bleeding and three of these patients required emergency thoracotomy (8).…”

Spontaneous Cerebral Air Embolism Associated with Remote Lung Surgery

“…Neurosurgical procedures, especially those involving the posterior fossa performed in the sitting position, carry a high risk of air embolism. Other causes are spine, orthopedic, cardiac, vascular, obstetric and gynecologic surgeries, trauma to the chest or vasculature, and decompression sickness [1][2][3][4]. Indwelling central or even peripheral venous catheters are the source in many cases [2,3].…”