Fatal Cerebral Air Embolus Complicating Multimodality Treatment of Esophageal Cancer

Cerebral arterial air emboli after stent insertion in esophageal cancer complicated with esophago-left atrial fistula: An autopsy case and review of the literature

Cerebral arterial air embolism is a rare and unexpected complication of advanced esophageal cancer. The entry of air to systemic circulation is an esophago-left atrial or pulmonary vein fistula formation. Herein, we report an autopsy case of a 64-year-old man. He was diagnosed esophageal cancer 2 years ago and underwent chemotherapy and concurrent chemoradiotherapy but the disease progressed, unfortunately. Then two metal stents were inserted into the middle thoracic esophagus as a palliation of dysphagia. After initiation of oral intake, he developed deterioration of consciousness. The cranial computed tomography showed cerebral arterial air emboli with multiple low-density areas. He failed to gain consciousness again and died one and half days later. In a literature survey, this autopsy case is the first presentation that confirmed histologically the close association between stent placement and formation of esophago-left atrial fistula. Due to the fatality of cerebral arterial air embolism, clinicians should keep in mind the possibility of this catastrophic complication after multimodality treatment of esophageal cancer.

Massive gas embolism revealed by two consecutive postmortem computed-tomography examinations

We present a case of unusual gas embolism in a 73-year-old man who was found in a state of cardiopulmonary arrest with an oxygen-supply tube connected to an intravenous catheter inserted into his median cubital vein. Postmortem computed tomography (PMCT) performed 27 h after death showed systemic gas distribution including intravascular gas, pneumothorax, pneumoperitoneum, pneumomediastinum, pneumoretroperitoneum and gastric emphysema. A second PMCT scan performed 116 h after death showed a marked decrease of air inside the body. The current case shows the importance of PMCT for visualization, quantification, and preservation of evidence for establishment of the cause of death in cases with suspected gas embolism. Our findings also indicate that performance of two PMCT examinations may be useful for differentiation of embolized gas from gas produced by putrefaction.

Cardiac arrest and possible seizure activity after vincristine injection

PURPOSE

A case of cardiac arrest and possible seizure activity after vincristine injection in a child is reported.

SUMMARY

A two-year-old African-American girl with stage IV hepatoblastoma arrived at a clinic to receive her fourth dose of vincristine as part of standard induction therapy. The patient had tolerated her first three doses of vincristine sulfate 0.7 mg (1.5 mg/m(2)) i.v. without any adverse events. Laboratory tests, including a comprehensive metabolic panel, conducted before chemotherapy administration were unremarkable. Shortly after the administration of vincristine, the patient experienced tonic extension of all four extremities and upward sustained deviation of the eyes. The patient then became limp and exhibited perioral cyanosis. Further evaluation revealed a lack of central pulses and a heartbeat. Cardiopulmonary resuscitation was begun with chest compressions and positive-pressure ventilation via a bag-mask device. After approximately 45 seconds, her pulses returned, and perioral cyanosis resolved. She was admitted to the pediatric intensive care unit for further evaluation. Her serum electrolyte, glucose, and ammonia concentrations were within normal limits. No yeast or bacteria were isolated from the patient's blood. No contributing cardiac or neurologic factors were identified. The patient recovered without sequelae and was discharged after 72 hours. Subsequent doses of vincristine were administered with no adverse events, and the patient successfully completed her treatment regimen.

CONCLUSION

A two-year-old girl with hepatoblastoma had seizurelike activity and cardiac arrest shortly after receiving i.v. vincristine. She received multiple doses of the drug before and after this event without a similar reaction. No contributing factors for the one-time event were identified.