Paradoxical Air Embolism Without Patent Foramen Ovale During Craniotomy in the Sitting Position

Abstract

Craniotomy in the sitting position entails risk for venous air embolism (VAE). A 50-year-old male underwent pineal region mass resection through a sitting position craniotomy. Intraoperative transesophageal echocardiography confirmed the absence of intracardiac shunt. During craniotomy, VAE was noted inside the patient’s right heart, leading to hemodynamic instability. After repositioning to the supine position, significant crossover of air into the left heart was noted. Postoperatively, multiple small embolic strokes were noted. Patients who undergo craniotomy in the sitting position and are not found to have a patent foramen ovale (PFO) are not free of risk for paradoxical air embolism (PAE).

Intraoperative venous air embolism in the non-cardiac surgery-the role of perioperative echocardiography in a case series report

“…Venous air embolism (VAE) is commonly iatrogenic due to infusion of bubbles adhering to the intravenous (IV) infusion set, residual air in drug-filled syrings, or ambient air intruding into the venous system in diverse surgical procedures (1). In previous reports, this incidence of VAE in neurosurgery conducted in the sitting position varies with a wide range from 4.9% to 76% (2,3). The prevalence of this adverse event during the laparoscopic surgery is less than 0.6%, while as high as 10-50% in hysteroscopic endometrial ablation procedure (4,5).…”

Comment on the article of R.S. Lakotko et al. “Risk and significance of venous air embolism at neurosurgical operations in the position of sitting at adults”

“…Сначала это были клинические наблюдения отдельных больных, которые погибали от ПВВЭ, но у которых на секции септальных дефектов обнаружить не удавалось (например, Singbartl et al [8]). Но были и результаты экспериментов на лабораторных животных, убедительно доказавшие принципиальную возможность такого перехода воздушных эмболов [9] и интраоперационные регистрации пассажа воздушных эмболов справа налево с помощью транспищеводной эхокардиографии [10]. Затем появились работы, в которых было показано, что некоторые фармакологические препараты, и в особенности ингаляционные анестетики (!…”