Abstract

Case Report

Cerebral arterial air embolism with anterior spinal cord syndrome after CT-guided hook-wire localization of Lung mass and pulmonary nodule

Noor Sameh Darwich*, Umran Ugur, Mark P Anstadt and J Pedoto

Published: 19 March, 2021 | Volume 5 - Issue 1 | Pages: 006-015

Systemic arterial air embolism (SAAE) is a rare but serious complication of CT-guided hook wire localization of pulmonary nodule usually with catastrophic and poor outcome. Hook wire needle localization is done pre-operatively by placing wire around or into the pulmonary nodule to provide the thoracic surgeon accurate location guidance of the target nodule for Video-Assisted Thoracoscopic Surgery (VATS) wedge resection with safety margins. Physicians should be aware of this possible complication during the procedure in order to rescue the patient promptly as it requires rapid diagnosis and management. We describe a 55-year-old male who underwent a CT-guided hook wire needle localization of left upper lobe lung cancer and left lower lobe pulmonary nodule prior to planned VATS wedge resection who developed altered mental status and bilateral lower extremities paralysis after wire placement was completed. His CT head demonstrated small air embolism in the left occipital area, confirming the diagnosis of cerebral air embolism and follow up CT and MRI of the head revealed multiple areas of brain infarction. In addition, he was diagnosed with anterior spinal cord syndrome (ACS), most likely due to anterior spinal artery ischemia from micro air embolism on the basis of clinical findings but with negative ischemic changes on MRI of the spinal cord. His mental status recovered but he remained paraplegic and transferred to inpatient rehabilitation service.

Read Full Article HTML DOI: 10.29328/journal.jnnd.1001044 Cite this Article Read Full Article PDF

Keywords:

Cerebral arterial air embolism; Hook-wire localization; Anterior spinal cord syndrome (ACS); Systemic arterial air embolism (SAAE)

References

  1. Shin KM, Lim JK, Kim CH. Delayed presentation of cerebellar and spinal cord infarction as a complication of computed tomography-guided transthoracic lung biopsy: a case report. J Med Case Rep. 2014; 8: 272. PubMed: https://pubmed.ncbi.nlm.nih.gov/25113016/
  2. Jang H, Rho JY, Suh YJ, Jeong YJ. Asymptomatic systemic air embolism after CT-guided percutaneous transthoracic needle biopsy. Elsevier Clin Imaging. 2019; 53: 49-57. PubMed: https://pubmed.ncbi.nlm.nih.gov/30312855/
  3. Kume A, Yoneyama S, Takahashi A, Watanabe, H. MRI of anterior spinal artery syndrome. J Neurol Neurosurg Psychiatry. 1992; 55: 838-840. PubMed: https://pubmed.ncbi.nlm.nih.gov/1402978/
  4. Boddu SR, Cianfoni A, Kim KW, Banihashemi MA, Pravata Em, et al. Spinal Cord Infarction and Differential Diagnosis. Neurovascular Imaging.
  5. Blanc P, Boussuges A, Henriette K, Sainty JM, Deleflie M. Iatrogenic cerebral air embolism: the importance of early hyperbaric oxygenation. Intensive Care Med. 2002; 28:559-563. PubMed: https://pubmed.ncbi.nlm.nih.gov/12029402/
  6. Yi JH, Choi PJ, Bang JH, Jeong SS, Cho JH. Systemic air embolism after computed tomography-guided hook wire localization: two case reports and literature review. J Thorac Dis. 2018; 10: E59-E64. PubMed: https://pubmed.ncbi.nlm.nih.gov/29600106/
  7. O'Dowd, LC, Kelley, MA. Air embolism. UpToDate. 2019; 1-39.
  8. Thomas R, Thangakunam B, Cherian RA, Gupta R, Christopher DJ. Cerebral air embolism complicating CT-guided transthoracic needle biopsy of the lung. Clin Respirat J. 2011; e1-e3. PubMed: https://pubmed.ncbi.nlm.nih.gov/21410896/
  9. Gossot D, Miaux Y, Guermazi A, Celerier M, Friga J. The hook-wire technique for localization of pulmonary nodules during thoracoscopic resection. Chest. 1994; 105: 1467-1469. PubMed: https://pubmed.ncbi.nlm.nih.gov/8181339/
  10. Horan T, Pinheiro P, Araujo LM, Santiago, FF, Rodrigues MR. Massive Gas Embolism During Pulmonary Nodule Hook Wire Localization. Ann Thorac Surg. 2002; 73: 1647-1649. PubMed: https://pubmed.ncbi.nlm.nih.gov/12022575/
  11. Sakiyama S, Kondo K, Matsuoka H, Yoshida M, Miyoshi T, et al. Fatal air embolism during computed tomography-guided pulmonary marking with a hook-type marker. J Thorac Cardiovasc Surg. 2003; 126: 1207-1209. PubMed: https://pubmed.ncbi.nlm.nih.gov/14566279/
  12. Sun D, Sui P, Zhang W, Zhang L, Xu H. Cerebral air embolism during percutaneous computed tomography scan-guided liver biopsy. J Can Res Ther. 2018; 14: 1650-1654. PubMed: https://pubmed.ncbi.nlm.nih.gov/30589054/
  13. Sato K, Miyauchi K, Shikata F, Murakami T, Yoshioka S, Kawachi K. Arterial Air Embolism during Percutaneous Pulmonary Marking under Computed Tomography Guidance. Jpn J Thorac Cardiovasc Surg. 2005; 53: 404-406. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/16095246
  14. Tagawa T, Takasu M, Ishida T. Asymptomatic Air Embolism After Computed Tomography Guided Lung Needle Marking. J Thorac Oncol. 2009; 4: 937-938. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/19550251
  15. Tagawa T, Takasu M, Ishida T. Asymptomatic Air Embolism After Computed Tomography-Guided Lung Needle Marking. J Thorac Oncol. 2009; 4: 938-938. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/19550251
  16. Muth CM, Shank ES. Gas Embolism. New Engl J Med. 2000; 342: 476-482. PubMed: https://pubmed.ncbi.nlm.nih.gov/10675429/
  17. Wang MY, Liu YS, An XB, Li K, Liu YJ, et al. Cerebral arterial air embolism after computed tomography-guided hook-wire localization of a pulmonary nodule. Med. 2019; 98: e15437. PubMed: https://pubmed.ncbi.nlm.nih.gov/31045810/
  18. Arnold BW, Zwiebel WJ. Percutaneous Transthoracic Needle Biopsy Complicated by Air Embolism. AJR. 2002; 178: 1400-1402. PubMed: https://pubmed.ncbi.nlm.nih.gov/12034605/
  19. Shi L, Zhang R, Wang Z, Zhou P. Delayed Cerebral Air Embolism Complicating Percutaneous Needle Biopsy of the Lung. Am J Med Sci 2013; 345: 501-503. PubMed: https://pubmed.ncbi.nlm.nih.gov/23276901/
  20. Kaichi Y, Kakeda S, Korogi Y, Nezu T, Aoki S, et al. Changes over Time in Intracranial Air in Patients with Cerebral Air Embolism: Radiological Study in Two Cases. Case Rep Neurol Med. 2015; 491017. PubMed: https://pubmed.ncbi.nlm.nih.gov/26640730/
  21. Fiore L, Frenk NE, Martins GLP, Viana PCC, de Menezes MR. Systemic Air Embolism after Percutaneous Lung Biopsy: A Manageable Complication. Radiol Case. 2017; 11: 6-14. PubMed: https://pubmed.ncbi.nlm.nih.gov/29299093/
  22. Djurberg H, Haddad M. Anterior spinal artery syndrome; Paraplegia following a segmental ischaemic injury to the spinal cord after oesophagectomy. Anaesthesia. 1995; 50: 345-348. PubMed: https://pubmed.ncbi.nlm.nih.gov/7747855/
  23. Klakeel M, Thompson J, Srinivasan R, McDonald F. Anterior spinal cord syndrome of unknown aetiology. Proc (Bayl Univ Med Cent) 2015; 28: 85-87. PubMed: https://pubmed.ncbi.nlm.nih.gov/25552812/
  24. Vargas MI, Gariani J, Sztajzel R, Barnaure-Nachbar I, Delattre BM, et al. Spinal Cord Ischemia: Practical Imaging Tips, Pearls, and Pitfalls. Am J Neuroradiol. 2015; 36: 825-830. PubMed: https://pubmed.ncbi.nlm.nih.gov/25324492/
  25. Wu CC, Maher MM, Shepard JA. Complications of CT-Guided percutaneous Needle Biopsy of the Chest: Prevention and management. AJR. 2011; 196: W678-W682. PubMed: https://pubmed.ncbi.nlm.nih.gov/21606253/
  26. Watts J, Wood B, Kelly A, Alvaro A. Stroke syndromes associated with DWI-negative MRI include ataxic hemiparesis and isolated internuclear ophthalmoplegia. Am Acad Neurol. 2013; 186-191. PubMed: https://pubmed.ncbi.nlm.nih.gov/29473634/
  27. Edlow BL, Hurwitz S, Edlow JA. Diagnosis of DWI-negative acute ischemic stroke A meta-analysis. Neurol. 2017; 89: 256-262. PubMed: https://pubmed.ncbi.nlm.nih.gov/28615423/
  28. Thurnher MM, Bammer R. Diffusion-weighted MR imaging (DWI) in spinal cord ischemia. Neuroradiology. 48: 795-801. PubMed: https://pubmed.ncbi.nlm.nih.gov/16977443/
  29. Makin SDJ, Doubal FN, Dennis MS, Wardlaw JM. Clinically Confirmed Stroke With Negative Diffusion-Weighted Imaging Magnetic Resonance Imaging. Stroke. 2015; 46: 3142-3148. PubMed: https://pubmed.ncbi.nlm.nih.gov/26419965/
  30. Kume A, Yoneyama S, Takahashi A, Watanabe H. MRI of anterior spinal artery syndrome. J Neurol Neurosurg Psychiatry. 1992; 55: 838-840. PubMed: https://pubmed.ncbi.nlm.nih.gov/1402978/
  31. Reale G. Not all that glitters is gold: MR-DWI negative ischemic stroke. 2017. PubMed: https://eso-stroke.org/strokeresearch/mr-dwi-negative-ischemic-stroke-not-all-strokes-glitter-in-dwi-sequences/.
  32. Rocha RD, Azevedo AA, Falsarella PM, Rahal Jr A, Garcia RG. Cerebral air embolism during CT-guided lung biopsy. Thorax. 2015; 70: 1099-1100. PubMed: https://pubmed.ncbi.nlm.nih.gov/26024689/
  33. Shin KM, Lim JK, Kim CH. Delayed presentation of cerebellar and spinal cord infarction a complication of computed tomography-guided transthoracic lung biopsy: a case report. J Med Case Rep. 2014; 8: 272. http://www.jmedicalcasereports.com/content/8/1/272.
  34. Romero JR, Frey JL, Schwamm LH, Demaerschalk BM, Chaliki HP, et al. Cerebral Ischemic Events Associated with “Bubble Study” for Identification of Right to left shunts. Strok. 2009; 40: 2343-2348. PubMed: https://pubmed.ncbi.nlm.nih.gov/19498192/
  35. Dedaj R, Preston IR. A case report: acute Stroke After Echocardiogram with bubble study in A patient with Patent Foramen Ovale and Chronic Thromboembolic Pulmonary hypertension. Am J Respir Crit Care Med. 2012; 185: A6170.
  36. McCarthy CJ, Behravesh S, Naidu SG, Oklu R. Air Embolism: practical tips for prevention and treatment. J Clin Med. 2016; 93: 1-13. PubMed: https://pubmed.ncbi.nlm.nih.gov/27809224/
  37. Balsara ZN, Burks DD. Hyperbaric Oxygen Therapy for Arterial Air Embolism. AJR. 2007; 188: W98-W98. PubMed: https://pubmed.ncbi.nlm.nih.gov/17179337/
  38. Leach RM, Rees PJ, Wilmshurst P. Hyperbaric Oxygen therapy. BMJ. 1998; 317: 1140. PubMed: https://pubmed.ncbi.nlm.nih.gov/9784458/
  39. Bou-Assaly W, Pernicano P, Hoeffner E. Systemic air embolism after transthoracic lung biopsy: A case report and review of the literature. World J Radiol. 2010; 28: 193-196. PubMed: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999016/
  40. Al-Ali WM, Browne T, Jones R. A Case of Cranial Air Embolism after Transthoracic Lung Biopsy. Am J Respirat Critical Care Med. 2012; 186: 1193-1195.
  41. Hiraki T, Fujiwara H, Sakurai J, Iguchi T, Gobara H, et al. Nonfatal Systemic Air Embolism Complicating Percutaneous CT-Guided Transthoracic Needle Biopsy: Four Cases From a Single Institution. Chest. 2007; 132: 684-690. PubMed: https://pubmed.ncbi.nlm.nih.gov/17699141/
  42. Bou-Assaly W, Pernicano P, Hoeffner E. Systemic air embolism after transthoracic lung biopsy: A case report and review of the literature. WJR. 2010; 2: 193-196. PubMed: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999016/
  43. Mansour A, Abdel Raouf S, Qandeel M, Swaidan M. Acute Coronary Artery Air Embolism Following CT-Guided Lung Biopsy. Cardiovasc Intervent Radiol. 2005; 28: 131-134. PubMed: https://pubmed.ncbi.nlm.nih.gov/15602640/
  44. McCarthy CJ, Behravesh S, Naidu SG, Oklu R. Air Embolism: Practical Tips for Prevention and Treatment. J Clini Med. 2016; 5: 93. PubMed: https://pubmed.ncbi.nlm.nih.gov/27809224/
  45. Moon RE, de Lisle dear G, Stolp BW. Treatment of decompression illness and iatrogenic gas Embolism. Respir Care Clin N Am. 1999; 5: 93-135. PubMed: https://pubmed.ncbi.nlm.nih.gov/10205814/
  46. Chuang DY, Sundararajan S, Sundararajan VA, Feldman DI, Xiong W. Accidental Air Embolism. An Uncommon cause of Iatrogenic Stroke. Stroke. 2019; 50: e183-e186.
  47. Robertson CE, Brown Jr RD, Wijdicks EFM, Rabinstein AA. Recovery after spinal cord infarcts/Long-term outcome in 115 patients. Neurology. 2012; 78: 114-121. PubMed: https://pubmed.ncbi.nlm.nih.gov/22205760/
  48. Masson C, Pruvo JP, Meder JF, Cordonnier C, Touze E, et al. Spinal cord infarction: clinical and magnetic resonance imaging findings and short-term outcome. J Neurol Neurosurg Psychiatry. 2004; 75: 1431-1435. PubMed: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1738740/
  49. Nedeltchev K, Loher TJ, Stepper F, Arnold M, Schroth G, et al. Long-Term Outcome of Acute Spinal Cord Ischemia Syndrome. Stroke. 2004; 35: 560-565. PubMed: PubMed: https://pubmed.ncbi.nlm.nih.gov/14726546/
  50. Sakiyama S, Kondo K, Matsuoka H, Yoshida M, Miyoshi T, et al. Fatal Air embolism during computed tomography-guided pulmonary marking with a hook-type marker. J Thorac Cardiovasc Surg. 2003; 126: 1207-1209. PubMed: https://pubmed.ncbi.nlm.nih.gov/14566279/
  51. Hellinger L, Keppler AM, Schoeppenthau H, Perras J, Bender R. Hyperbaric oxygen therapy for iatrogenic arterial gas embolism after CT-guided lung biopsy. Anaesthesist. 2019; 68: 456-460. PubMed: https://pubmed.ncbi.nlm.nih.gov/31264050/
  52. Arai H, Tajiri M, Ando K, Okudela K, Iwasawa T, Masuda M. Possible Complication of Marking Hook Wire Entry into the Systemic Circulation during Video-Assisted Thoracoscopic Surgery. Int J Respir Pulm Med. 2016; 3: 060.
  53. Lattin G, O‘Brien W, McCrary B, Kearney P, Gover D, et al. Massive systemic Air Embolism treated with Hyperbaric Oxygen Therapy Following CT-guided Transthoracic Needle Biopsy of a Pulmonary Nodule. J Vasc Interv Radiol. 2006; 17: 1355-1358. PubMed: https://pubmed.ncbi.nlm.nih.gov/16923984/
  54. Brito C, Graca J, Vilela P. Cerebral Air Embolism: The importance of Computed Tomography Evaluation. J Med Cases. 2020; 11: 394-399.
  55. Goldney B, Schonherr E, Freund MC, Haslauer M, Petersen J, et al. Measures to prevent Air Embolism in transthoracic Biopsy of the lung. AJR Am J Roentgenol. 2017; 208: W184-W191. PubMed: https://pubmed.ncbi.nlm.nih.gov/28301208/

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