Cerebral air embolism treated with hyperbaric oxygen therapy following percutaneous transthoracic computed tomography-guided needle biopsy of the lung

Abstract

A 71-year-old man presented with cough and sputum for 12 months. Chest radiography showed a homogeneous opacity in the right lower lobe. Computed tomography (CT) showed a nodular opacity, 2 cm in diameter, in the posterior segment of the right lower lobe. Mild emphysematous changes were also seen. With the patient in a prone position, a 19-gauge 7.8-cm introducer was placed in the lesion during a single inspiratory breath-hold. A coaxial 20-gauge automated needle was inserted through the introducer using a biopsy gun. Although the patient did not complain of any symptoms, postbiopsy CT showed air in the left ventricle and ascending aorta. After 5 h of bed rest, we found weakness in his left lower extremity. He was transferred to a hyperbaric oxygen chamber and recovered the next day. Air embolism is a rare, potentially fatal complication of percutaneous lung biopsy. Although the true effect of hyperbaric oxygen therapy is controversial, knowledge regarding the prompt management of such cases may help radiologists who perform this procedure.

Cerebral arterial air embolism after computed tomography-guided hook-wire localization of a pulmonary nodule

“…It is currently recognized as the 1st-line therapy for the treatment of systemic air embolism. [11] Early hyperbaric oxygen therapy improves prognosis of patients with cerebrovascular air embolism and reduces their mortality rate to 7%. [12] The present patient was promptly administered hyperbaric oxygen therapy.…”

Air embolism following bronchoscopy with fine needle aspiration: An unexpected complication

“…Second, if internal airway pressure distal to the scope were to rise, the risk of embolus is thought to increase. For example, actions that mimic valsalva manoeuvre, such as coughing and straining, during the procedure, can create a sudden pressure increase distal to the needle, thus inducing embolus [ [3] , [4] , [5] , [6] , [17] , [18] , [19] , [20] ]. A potential learning point for physicians is to consider increasing sedation in patients who show signs of airway resistance during the procedure, including coughing, straining or deep breathing, to reduce risk of embolus.…”

“…A further hypothesis suggests that a needle may penetrate simultaneously at an air-containing space, such as a nearby pulmonary alveolar space or bronchus, and a nearby pulmonary vein, which can create a communicating fistula [ [3] , [4] , [5] , [6] , [17] , [18] , [19] , [20] ]. Lastly, radiology literature suggests an association between the size of the needle used and increased incidence of air emboli [ 6 ].…”

“…2) A large quantity of oxygen can then dissolve into the plasma. 3) Increased oxygen is also diffused out into the tissue [ 18 ]. In addition, the patient can be placed in the left lateral decubitus position with a lowered head [ 5 , 6 , 15 , 20 ].…”

Treatment of Massive Systemic Air Embolism During Lung Biopsy

“…Then cough, straining, or Valsalva maneuvers can increase the pressure in the air-containing space, resulting in air embolism. [2][3][4][5][6][7][8][9][10][11]3] Some factors are thought to be contributors: Coughing during the procedure, positive-pressure ventilation, a needle tip placed within pulmonary veins, and procedures performed for a cystic or cavitary lesion and in patients with vasculitis. [8] Some authors postulated an increased probability of gas embolism related to the size of the needle and the coaxial techniques since larger needles have an increased risk of involvement in a pulmonary vein and the coaxial method increases the risk of contact with the atmosphere after removal of the internal stylet.…”