Cerebral air embolism via port catheter and endoscopic retrograde cholangio-pancreatography

Abstract

BackgroundCerebral air embolism (CAE) is a critical clinical condition necessitating rapid diagnosis and therapeutic measures.MethodsThe authors describe two patients with lethal CAE.ResultsAn 81-year-old man rapidly developed coma with tetraplegia. CT-scan revealed prominent CAE whereby the entry of the air was via a port catheter for parenteral nutrition. A 45-year-old man with severe alcohol-toxic multiple organ damage needed endoscopic retrograde cholangio-pancreatography (ERCP) and a second esophagogastroscopy. After an epileptic seizure, the CT-scan of the brain showed small amounts of cerebral air in the posterior right hemisphere and in the sagittal superior sinus. Despite critical care the patient died.ConclusionCAE is a neurocritical emergency case. Early CT-scan of the brain can detect air, guide further therapy, and contribute to the assessment of the prognosis.

Gas embolism during endoscopic retrograde cholangiopancreatography: diagnosis and managementn

“…Cardiovascular signs and symptoms include chest pain, dizziness, crackles, elevated jugular venous pressure, acute onset right side heart failure, tachycardia or bradycardia, hypotension, mill wheel murmur (loud churning sound likely from mixing of air and blood in the right ventricle heard throughout the cardiac cycle), cardiac arrest, arrhythmias like supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, asystole, and pulseless electrical activity [30-34]. Neurological signs and symptoms include headache, seizures, focal neurological deficits, acute change in mental status or failure to regain consciousness after the procedure, hemiparesis, conjugate eye deviation, pupillary dilation, paraplegia, quadriparesis, skin mottling, bilateral extensor plantar reflex, and coma [35-38] (Fig. 2).…”

“…Therapeutic hypothermia in cerebral air embolism after cardiac arrest can be neuroprotective, more studies need to be done to make it standard of care in cerebral air embolism [85]. However, therapeutic hypothermia is not recommended in active infection or coagulation disorder [38,86].…”

Clinical Presentation, Diagnosis, and Management of Air Embolism During Endoscopic Retrograde Cholangiopancreatography

“…Cardiovascular symptoms and signs include chest pain, dizziness, tachycardia or bradycardia, crackles, acute onset right-sided heart failure, hypotension, elevated jugular venous pressure, mill wheel murmur (loud churning sound likely from mixing of air and blood in the right ventricle that is heard throughout the cardiac cycle), cardiac arrest, arrhythmias like supraventricular tachycardia (SVT), ventricular tachycardia (VT), asystole or pulseless electrical activity [25, 31, 33-35]. Seizures, headache, focal neurological deficits, paraplegia or quadriparesis, altered mental status or failure to regain consciousness after the procedure, hemiparesis, pupillary dilation, skin mottling, and coma are some of the neurological signs and symptoms that may be present if cerebral involvement occurs [36-39]. Pulmonary symptoms and signs include respiratory failure, tachypnea, cyanosis, rales and wheezing [40].…”

When in Trouble Think of the Bubble: Paradoxical Cerebral Arterial Gas Embolism after Endoscopic Retrograde Cholangiopancreatography

“…The United Stated of America National Inpatient Sample from 1998 to 2013 reported the occurrence of air embolism in 3.32 per 100,000 ERCP procedures [ 5 ]. With only 60 cases of air embolism reported (and even fewer related to paradoxical air embolism) [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 ], we aimed to report a case of paradoxical cerebral air embolism in a patient undergoing ERCP due to a common bile duct (CBD) stricture and to provide a mini-review of this clinical entity that can serve as a bedside quick reference guide for endoscopists worldwide.…”