Venous air embolism during microelectrode recording in deep brain stimulation surgery in an awake supine patient

Abstract

Venous air embolism (VAE) is a potentially serious complication in neurosurgery. It occurs most commonly during craniotomy in the sitting position. Diagnosis is difficult in awake patients on spontaneous ventilation due to different clinical manifestations. Prompt diagnosis and treatment are essential. We report venous air embolism in an awake patient undergoing deep brain stimulation for Parkinson's disease and discuss the pathogenesis, prevention and management of VAE.

An unusual case of repeated venous air embolism during awake bilateral deep brain stimulation surgery

“…An operative site more than 5 cm above the right atrium has been mentioned as one of the potential risk factors. 6 The mortality and morbidity of VAE can be affected by the rate and the volume of air entrainment, as well as the position of the patient. 7 In awake craniotomy as in DBS surgery, the other additional risk factors for VAE are awake condition, spontaneous ventilation and head elevation.…”

“…However, the detection of VAE may be further delayed in patients undergoing awake procedures because VAE presentation is more atypical if it is compared with the more classical features of VAE in patients who are under general anaesthesia. 5,6 The severity of clinical presentation is determined by the volume of air, as well as the rate of air entrainment. An acute amount of air of more than 2 ml/kg is more likely to cause chest pain, right heart failure and cardiovascular collapse.…”

“…2,3 There have been a few reported cases of VAE in DBS surgery that raise a concern for extra monitoring and prompt management of this situation. [4][5][6] All previous reported cases occurred during the burr hole and insertion of the electrodes on only one side of the procedure. However, in our case the suspicious symptoms occurred repeatedly during both sides of the procedure.…”

Embolismo aéreo venoso en neurocirugía

“…La presencia de aire en los senos venosos duramadres, en la vena cortical o en el plejo pterigoideo harían el diagnóstico 28 .…”

“…En este estudio se encontró una relación entre la posición de la cabeza elevada y la aparición del embolismo aéreo, incluso sin que este volumen de aire repercutiera en la estabilidad hemodinámica del paciente.Manifestaciones clínicasCuando el paciente está despierto durante el procedimiento quirúrgico, el EAV se puede manifestar como un episodio de tos asociada a desaturación arterial de oxígeno, hipotensión arterial 26 , disnea, dolor precordial y náuseas. Puede además auscultarse un soplo cardíaco de novo27,28 .En el postoperatorio los pacientes pueden cursar con deterioro neurológico, que puede ir desde lesiones neurológicas focales hasta el coma29 . Pueden cursar también con alteraciones cardiovasculares como insuficiencia cardíaca derecha aguda, hipertensión pulmonar, isquemia miocárdica, edema pulmonar asociado 30 y colapso cardiovascular31 .…”