Stress-induced cardiomyopathy complicating a stroke caused by an air embolism

Incidence, risk factors, and prognostic indicators of symptomatic air embolism after percutaneous transthoracic lung biopsy: a systematic review and pooled analysis

Objectives

To determine the incidence, risk factors, and prognostic indicators of symptomatic air embolism after percutaneous transthoracic lung biopsy (PTLB) by conducting a systematic review and pooled analysis.

Methods

We searched the EMBASE and OVID-MEDLINE databases to identify studies that dealt with air embolism after PTLB and had extractable outcomes. The incidence of air embolism was pooled using a random effects model, and the causes of heterogeneity were investigated. To analyze risk factors for symptomatic embolism and unfavorable outcomes, multivariate logistic regression analysis was performed.

Results

The pooled incidence of symptomatic air embolism after PTLB was 0.08% (95% confidence interval [CI], 0.048–0.128%; I² = 45%). In the subgroup analysis and meta-regression, guidance modality and study size were found to explain the heterogeneity. Of the patients with symptomatic air embolism, 32.7% had unfavorable outcomes. The presence of an underlying disease (odds ratio [OR], 5.939; 95% CI, 1.029–34.279; p = 0.046), the use of a ≥ 19-gauge needle (OR, 10.046; 95% CI, 1.103–91.469; p = 0.041), and coronary or intracranial air embolism (OR, 19.871; 95% CI, 2.725–14.925; p = 0.003) were independent risk factors for symptomatic embolism. Unfavorable outcomes were independently associated with the use of aspiration biopsy rather than core biopsy (OR, 3.302; 95% CI, 1.149–9.492; p = 0.027) and location of the air embolism in the coronary arteries or intracranial spaces (OR = 5.173; 95% CI = 1.309–20.447; p = 0.019).

Conclusion

The pooled incidence of symptomatic air embolism after PTLB was 0.08%, and one-third of cases had sequelae or died. Identifying whether coronary or intracranial emboli exist is crucial in suspected cases of air embolism after PTLB.

Key Points

• The pooled incidence of symptomatic air embolism after percutaneous transthoracic lung biopsy was 0.08%, and one-third of patients with symptomatic air embolism had sequelae or died.

• The risk factors for symptomatic air embolism were the presence of an underlying disease, the use of a ≥ 19-gauge needle, and coronary or intracranial air embolism.

• Sequelae and death in patients with symptomatic air embolism were associated with the use of aspiration biopsy and coronary or intracranial locations of the air embolism.

A case report of cerebral arterial gas embolism (CAGE) associated with Takotsubo cardiomyopathy

A 43-year-old female scuba diver was retrieved and treated following a rapid ascent and presumed cerebral arterial gas embolism (CAGE). She subsequently developed respiratory distress and was found to have Takotsubo cardiomyopathy, with transient left ventricular dysfunction, elevated cardiac enzymes, and normal CT coronary angiography. We believe this to be the first report of CAGE associated with Takotsubo cardiomyopathy.

CNS disease triggering Takotsubo stress cardiomyopathy

There are a number of hereditary and non-hereditary central nervous system (CNS) disorders, which directly or indirectly affect the heart (brain-heart disorders). The most well-known of these CNS disorders are epilepsy, stroke, infectious or immunological encephalitis/meningitis, migraine, and traumatic brain injury. In addition, a number of hereditary and non-hereditary neurodegenerative disorders may impair cardiac functions. Affection of the heart may manifest not only as arrhythmias, myocardial infarction, autonomic impairment, systolic dysfunction/heart failure, arterial hypertension, or pulmonary hypertension, but also as stress cardiomyopathy (Takotsubo syndrome, TTS). CNS disease triggering TTS includes subarachnoid bleeding, epilepsy, ischemic stroke, intracerebral bleeding, migraine, encephalitis, traumatic brain injury, PRES syndrome, or ALS. Usually, TTS is acutely precipitated by stress triggered by various different events. TTS is one of the cardiac abnormalities most frequently induced by CNS disorders. Appropriate management of TTS from CNS disorders is essential to improve the outcome of affected patients.

CNS-disease affecting the heart: brain-heart disorders

There are a number of hereditary and non-hereditary central nervous system (CNS) disorders, which directly or indirectly affect the heart (brain-heart disorders). The most well-known of these CNS-disorders are epilepsy, stroke, subarachanoid bleeding, bacterial meningitis, and head injury. In addition, a number of hereditary and non-hereditary neurodegenerative disorders may impair cardiac functions. Affection of the heart may manifest as arrhythmias, cardiomyopathy, or autonomic dysfunction. Rarer cardiac complications of CNS disorders include heart failure, systolic or diastolic dysfunction, myocardial infarction, arterial hypertension, or pulmonary hypertension. Cardiomyopathy induced by hereditary CNS disease mainly include stress-induced myocardial dysfunction, known as Takotsubo syndrome (TTS). CNS disease triggering TTS includes epilepsy, ischemic stroke, subarachnoid bleeding, or PRES syndrome. Arrhythmias induced by hereditary CNS disease include supraventricular or ventricular arrhythmias leading to palpitations, dizziness, vertigo, fainting, syncope, (near) sudden cardiac death, or sudden unexplained death in epilepsy (SUDEP). Appropriate management of cardiac involvement in CNS-disorders is essential to improve outcome of affected patients.