Pearls &amp; Oy-sters: Enhancing vigilance for detection of cerebral air embolism

Mirtchev, Dimitre; Mehta, Tapan; Daniel, Annie; Finstein, Thomas; McCullough, Louise D.

doi:10.1212/wnl.0000000000006324

Cited by 6 publications

(6 citation statements)

References 9 publications

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“…From there it then rose to the cerebral venous circulation against the normal direction of flow. Once the air entered the parenchyma, neutrophils were activated, and stasis was achieved, postulating the creation of a subsequent infarction versus thrombosis [2].…”

Section: Discussionmentioning

confidence: 99%

“…Air embolisms are infrequent and potentially fatal and may occur as a complication of surgery, endoscopic procedures, vascular catheterization, trauma, or positive pressure ventilation. Air embolism occurs when there is both direct communication and a pressure gradient between air and the vasculature [1,2]. Most air embolisms are due to iatrogenic causes.…”

Section: Introductionmentioning

confidence: 99%

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Retrograde Cerebral Air Embolism Associated With Bronchovenous Fistula

Uts¹,

Li²,

Kurbanov³

2023

Cureus

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Cerebral air embolism is a rare event and predominantly iatrogenic. Here we present a case of spontaneous intravascular cerebral air embolism caused by lung cancer, which is among the other previously reported cases worldwide. A 69-year-old man with small cell lung carcinoma presented after being found unconscious. Computed tomography (CT) of the chest revealed a lung mass eroding into the superior vena cava (SVC) and with communication to the right upper lobe bronchus. As the patient's neurologic status deteriorated further, serial CT scans of the brain noted multiple air emboli with development of left cerebral infarction, and death followed shortly after. This case highlights the rapid progression of this rare condition and thereby the need to be familiar with the clinical setting in which the presence of cerebral air embolism can occur.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Retrograde Cerebral Air Embolism Associated With Bronchovenous Fistula

Uts¹,

Li²,

Kurbanov³

2023

Cureus

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“…If enough air enters and overwhelms the lung's filtration system, it can diffuse into the arterial side. [ 7 ] The most common intracardiac shunt is a patent foramen ovale. [ 8 ] Other shunts, such as atrial or ventricular septal defects, pulmonary shunts and arterio-venous shunts could potentially cause systemic air embolism.…”

Section: Discussionmentioning

confidence: 99%

Transesophageal echocardiography detection of air embolism during endoscopic surgery and validity of hyperbaric oxygen therapy

Guo

Wang²,

Wang³

et al. 2021

Medicine

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Introduction: Air embolism has the potential to be serious and fatal. In this paper, we report 3 cases of air embolism associated with endoscopic medical procedures in which the patients were treated with hyperbaric oxygen immediately after diagnosis by transesophageal echocardiography. In addition, we systematically review the risk factors for air embolism, clinical presentation, treatment, and the importance of early hyperbaric oxygen therapy efficacy after recognition of air embolism. Patient Concerns: We present 3 patients with varying degrees of air embolism during endoscopic procedures, one of which was fatal, with large amounts of gas visible in the right and left heart chambers and pulmonary artery, 1 showing right heart enlargement with increased pulmonary artery pressure and tricuspid regurgitation, and 1 showing only a small amount of gas images in the heart chambers. Diagnoses: Based on E T CO 2 and transesophageal echocardiography (TEE), diagnoses of air embolism were made. Interventions: The patients received symptomatic supportive therapy including CPR, 100% O 2 ventilation, cerebral protection, hyperbaric oxygen therapy and rehabilitation. Outcomes: Air embolism can causes respiratory, circulatory and neurological dysfunction. After aggressive treatment, one of the 3 patients died, 1 had permanent visual impairment, and 1 recovered completely without comorbidities. Conclusions: While it is common for small amounts of air/air bubbles to enter the circulatory system during endoscopic procedures, life-threatening air embolism is rare. Air embolism can lead to serious consequences, including respiratory, circulatory, and neurological impairment. Therefore, early recognition of severe air embolism and prompt hyperbaric oxygen therapy are essential to avoid its serious complications.

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“…Earlier studies reported 80-90% morbidity and mortality, but this number has been more recently reported at closer to 21% given earlier recognition and treatment when air embolism suspected [27]. Higher volumes of embolic air, rate of embolic air accumulation, importance of affected cerebral territory, focal motor deficits (especially hemiparesis), presence of Babinski sign, presence of gyriform air, initial disturbance of consciousness, older age, and retrograde ascension of venous air have all been associated with worse prognosis [20,[27][28][29]. Precautions should be taken during placement and removal of central and even peripherally placed IV lines (avoiding any air entry into the line itself, Trendelenburg position when placing IJ or subclavian lines, Valsalva during line removal).…”

Section: Discussionmentioning

confidence: 99%

Paradoxical and Retrograde Air Embolism from Pressurized Peripheral Bolus

Santucci

Mullaguri

Battineni

et al. 2021

Case Reports in Neurological Medicine

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Introduction. Cerebral air embolism is a rare, yet serious neurological occurrence with unclear incidence and prevalence. Here, we present a case of fatal cerebral arterial and venous cerebral gas embolism in a patient with infective endocarditis and known large right-to-left shunt and severe tricuspid regurgitation following pressurized fluid bolus administration. Case Presentation. A 32-year-old female was admitted to the medical intensive care unit from a long-term acute care facility with acute on chronic respiratory failure. Her medical history was significant for intravenous heroin and cocaine abuse, methicillin-sensitive Staphylococcus aureus tricuspid valve infective endocarditis on vancomycin, patent foramen ovale, septic pulmonary embolism with cavitation, tracheostomy with chronic ventilator dependence, multifocal cerebral infarction, hepatitis C, nephrolithiasis, anxiety, and depression. After intravenous fluid administration, she became unresponsive with roving gaze, sluggish pupils, and hypotensive requiring vasopressors. CT of the brain showed diffuse arterial and venous cerebral air embolism secondary to accidental air administration from fluid bolus. Magnetic resonance imaging of the brain showed diffuse global anoxic injury and flattening of the globe at the optic nerve insertion. Given poor prognosis, her family chose comfort measures and she died. Conclusions. Fatal cerebral air embolism can occur through peripheral intravenous routes when the lines are inadequately primed and fluids administered with pressure. Caution must be exercised in patients with right-to-left shunting as air may gain access to systemic circulation.

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Pearls & Oy-sters: Enhancing vigilance for detection of cerebral air embolism

Abstract: Pearls• Cerebral air emboli (CAE) are scattered, small, distally located, and characteristically of low density on CT scan. • CAE should be considered as a stroke etiology in appropriate cases.• Prevention is a key treatment strategy.

Cited by 6 publications

References 9 publications

Retrograde Cerebral Air Embolism Associated With Bronchovenous Fistula

Retrograde Cerebral Air Embolism Associated With Bronchovenous Fistula

Transesophageal echocardiography detection of air embolism during endoscopic surgery and validity of hyperbaric oxygen therapy

Paradoxical and Retrograde Air Embolism from Pressurized Peripheral Bolus

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