Neurological picture. Multiple cerebral air emboli during upper gastrointestinal endoscopy

Massive air embolism as a complication of upper gastrointestinal endoscopy: A case report illustrating a stroke mimic, literature review, and suggested management

Cerebral air embolism should be considered in case of stroke symptoms during any invasive procedure. Transport to a hospital with neurosurgical/hyperbaric oxygen treatment (HBOT) facility could improve the outcome for the patient. Absence of air on computed tomography (CT) scan should not disqualify a patient from HBOT if air embolism is suspected.

Death Resulting from Pneumocephalus Complicating Endoscopic Food Bolus Retrieval in a Patient with Eosinophilic Esophagitis

Pneumocephalus is a rare complication of esophagogastroduodenoscopy (EGD), but existing literature does not discuss pneumocephalus surrounding endoscopic food bolus retrieval. We present a death involving pneumocephalus complicating endoscopic food removal from the esophagus. A 40-year-old man presented with dysphagia and suprasternal discomfort 12 hours following chicken ingestion. On flexible endoscopy, chicken was visualized in the distal esophagus. After successful retrieval, a mucosal laceration was noted where the chicken had been lodged. He was unarousable following the procedure and was emergently transported to a hospital, where computed tomography scanning showed pneumocephalus. He was later declared brain dead. The case was referred for medicolegal autopsy. The brain was examined first, revealing rare air bubbles within meningeal vessels and numerous, diffuse petechiae-like hemorrhages within the brain parenchyma. The esophageal mucosa had focal discoloration and a partial thickness laceration; microscopic examination revealed eosinophilic esophagitis. Eosinophilic esophagitis is a known risk factor for food bolus impaction and should be suspected in such patients. Pneumocephalus is a rare possible complication of EGD for food bolus retrieval. In patients unresponsive after endoscopy, radiographic detection of potential pneumocephalus should be encouraged to enable timely therapy and improved outcomes, or to supplement autopsy in the event of patient death. Forensic pathologists should understand that pneumocephalus is a potential mechanism of injury/death in patients experiencing esophageal trauma, including injury incurred during EGD.

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

Background

Cerebral air embolism (CAE) is a critical clinical condition necessitating rapid diagnosis and therapeutic measures.

Methods

The authors describe two patients with lethal CAE.

Results

An 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.

Conclusion

CAE 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.

Therapeutic hypothermia in cerebral air embolism: a case report

BACKGROUND

Cerebral air embolism is a life-threatening complication of various diagnostic and therapeutic procedures. Hyperbaric oxygenation is considered to be the cornerstone of its treatment.

CASE DESCRIPTION

We report a patient with cerebral air embolism after endoscopy of a perineal abscess. Immediate CT imaging confirmed the diagnosis and MRI showed cortically localized areas of restricted diffusion along the gyri. Since hyperbaric oxygenation was not available, moderate hypothermia was applied for neuroprotection.

CONCLUSION

This case illustrates a rare complication of endoscopic interventions, and imaging characteristics of cerebral air embolism were described. Furthermore, we discuss the potential utility of therapeutic hypothermia in cerebral air embolism.