Air embolism during awake craniotomy

Abstract

SummaryA case of venous air embolism during awake craniotomy is described. Chest pain and electrocardiographic changes were the major presenting features. Capnography detected a decrease in end-tidal carbon dioxide and demonstrates its use as an aid in the diagnosis of air embolism in the awake patient. Following this episode persistent hypoxaemia developed secondary to acute pulmonary oedema and a pleural effusion.

Venous air embolism during awake craniotomy in a supine patient

“…The rise in blood pressure could be because the patient was awake and distressed due to cough and sedation had been stopped. In contrast, in the case report described by Scuplak et al, 4 the patient presented with hypoxemia and chest pain with ST-T changes on ECG. Treatment was initiated on the presumptive diagnosis of myocardial ischemia.…”

“…A A search of the literature revealed only one case report on VAE in an awake craniotomy. 4 The risk of VAE is increased with the transmission of negative intrathoracic pressure to the central veins. Thus it is more likely to occur with spontaneous breathing, deep inspiration, dyspnea, hypovolemia and in the upright position.…”

“…[1][2][3] However, its incidence in conscious patients during an awake craniotomy has not been widely discussed or reported. 4 An awake craniotomy is usually performed in order to allow for neurological assessment of the patient during the resection of a lesion close to areas of eloquent brain function. 5 During an awake craniotomy, the diagnosis of a VAE may be difficult because of the use of limited monitoring and the lack of a high index of suspicion.…”

Venous Air Embolism during Deep Brain Stimulation Surgery in an Awake Supine Patient

“…Patients in these reports were undergoing awake craniotomy in a sitting or semisitting position. Balki et al [3] and Scuplak et al [4] described intraoperative VAE in 2 patients undergoing awake craniotomy in the supine position with 20° head up tilt for tumor resection. Most recently, Moitra et al [8] reported VAE in a patient undergoing placement of bilateral deep brain stimulators in the supine position with 30° head elevation immediately after the burr hole.…”

“…Venous air embolism (VAE) is a known complication during neurosurgical procedures performed in head-elevated procedures under general anesthesia and has been previously reported in patients undergoing awake neurosurgical procedures for brain tumors [3,4] and pallidotomy [5][6][7] for PD. We describe a case of intraoperative VAE in an awake, supine patient while undergoing DBS surgery for PD who presented with coughing, tachypnea and hypoxemia.…”