American Journal of Emergency Medicine 32 (2014) 194.e1–194.e2
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Massive cerebrovascular air embolism during posttraumatic cardiopulmonary resuscitation Abstract Air embolism is known to be a complicating factor in several clinical settings, including thoracic, cardiovascular, and neurosurgical operations; central line placement; and penetrating thoracic and cranial trauma. There are, however, only few case descriptions for cardiopulmonary resuscitation massive cerebral air embolism, and the frequency of this supposedly rare complication is unknown. Computed tomography is useful for showing cerebral air embolism. In this report, we present a 16-year-old adolescent girl with cerebrovascular air embolism on computed tomographic examination after a posttraumatic cardiopulmonary resuscitation and discuss the reasonable mechanisms of cerebrovascular air embolism. Cerebral air embolism (CAE) is not a rare condition. It can be caused by decompression disease or trauma or can occur iatrogenically [1]. Air embolism can develop following various clinical conditions such as thoracic, cardiovascular, and neurosurgical operations; hemodialysis; placement of central lines; and penetrating thoracic and cranial traumas. However, the volume of intravascular air is generally small in such embolies. Massive air embolism in major cerebral vessels is quite rare [2]. The accurate diagnosis of cerebrovascular air embolism is difficult and frequently is made in late stage or in necropsy. The aim of this article was to present the imaging findings of a traumatized adolescent with massive air embolism occurring during computed tomographic (CT) scanning while she was on cardiopulmonary resuscitation (CPR) and to discuss the case in the light of pertinent literature. A 16-year-old adolescent girl was severely head injured in a traffic accident. She was in cardiopulmonary arrest when she was brought to the emergency department by ambulance. She presented with dilated pupils, chest injury, and no cardiac activity. Cardiopulmonary resuscitation was immediately started. Computed tomography imaging of the cranium was carried out to check potential brain injury as the patient was still on CPR. During CT scanning, a sudden facial subcutaneous emphysema developed in the patient, followed by irreversible cardiopulmonary arrest (Fig. 1). The CT imaging demonstrated neither skull fracture nor extravascular pneumocephalus. The only positive finding was massive air in the cerebral arteries. Air was observed in bilateral internal carotid, bilateral external carotid, and vertebral arteries (Fig. 2). There was air in the internal carotid artery but no cervical trauma. Although systemic circulation was restored, the patient died 1 hour after admission. Cerebral air embolism may be caused by iatrogenic or traumatic introduction of air into the arterial or venous circulation. It may occur as a complication of angiography or via a peripheral or central venous line [3,4]. It may also occur in thoracic, cardiovascular, and 0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
neurosurgical surgeries; thoracic or cranial trauma; and during hemodialysis [5,6]. Computed tomographic scanning is the imaging modality used to show CAE [5]. However, CT demonstration of air in almost all the major cerebral arteries is extremely rare. It is assumed that air particles may enter the arterial circulation in 3 ways: by direct passage, by passage through shunts between main bronchi and pulmonary veins, and by passage through cardiac septal defects [7]. Hashimoto et al [8] have claimed that during artificial respiration, air passing through the traumatic shunts between main bronchi and pulmonary veins enters the heart and by external cardiac message is sent into intracerebral arteries. In our case, one of the mentioned mechanisms of CAE might have been involved. However, that the massive air embolization in all cerebral arteries in our case leads us to think that stepwise, the air first passed through the traumatic shunts during CPR, entered the heart and then general blood circulation and finally cerebral arteries. The massive CAE has a high rate of mortality. The diagnosis of cerebrovascular air embolism in a trauma patient is particularly difficult. Computed tomographic imaging is a very helpful and fast method used for diagnosis. In CT imaging, in light cases, air embolus is observed as small air particles, whereas in severe cases, as massive air filling the blood vessels. The distribution of intracranial air may depend on the quantity of air and the position of the patient. Because of massive air embolism in our patient, we observed a diffuse distribution of air in the anterior-posterior system. Traumas are among the primary causes of death in the first 4 decades of life, and 25% of deaths due to trauma are caused by chest trauma. Some of chest trauma patients may need CPR. In conclusion, although rare, one should consider the possible occurrence of massive air embolism during performing CPR on such patients.
Ramazan Buyukkaya Department of Radiology Duzce University, School of Medicine Duzce, Turkey E-mail address: [email protected] Ömer Aydın Bahattin Hakyemez Müfit Parlak Department of Radiology Uludag University, School of Medicine Bursa, Turkey http://dx.doi.org/10.1016/j.ajem.2013.09.020
194.e2
R. Buyukkaya et al. / American Journal of Emergency Medicine 32 (2014) 194.e1–194.e2
Fig. 1. Axial head CT in lung (A) and bone (B) windows demonstrates facial subcutaneous emphysema (*) and vascular structure (white arrows).
Fig. 2. A brain CT scan revealed cerebral air embolism, especially in the arterial-circulation territory.
References [1] Alper F, Kantarci M, Onbas O, Okur A, Ceviz N. Three-dimensional spiral CT reconstruction in a patient with massive cerebral air embolism. Emerg Radiol 2004;11:87e8. [2] Wijman CA, Kase CS, Jacobs AK, Whitehead RE. Cerebral air embolism as a cause of stroke during cardiac catheterization. Neurology 1998;51:318–9. [3] Rubinstein D, Symonds D. Gas in the cavernous sinus. AJNR Am J Neuroradiol 1994;15:561–6. [4] Takahashi W, Yoshii F, Ohsuga S, Izumi Y, Shinohara Y. Two patients with paradoxical cerebral air embolism due to accidental disconnection of a subclavian intravenous catheter. Jpn J Stroke 1995;17:89–94.
[5] Hwang TL, Fremaux R, Sears ES, et al. Confirmation of cerebral air embolism with computerized tomography. Ann Neurol 1993;13:214–5. [6] Nakao N, Moriwaki H, Oiwa Y. Barotraumatic cerebral air embolism following scuba diving. Brain Nerve 1990;42:1097–100. [7] Atalar MH, Oztoprak B, Erdinc P, Ozum U. Diffuse cerebrovascular air embolism on CT secondary to cardiopulmonary resuscitation. Turk J Trauma Emerg Surg 2007;13(4):319–21. [8] Hashimoto Y, Yamaki T, Sakakibara T, Matsui J, Matsui M. Cerebral air embolism caused by cardiopulmonary resuscitation after cardiopulmonary arrest on arrival. J Trauma 2000;48:975–7.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Massive cerebrovascular air embolism during posttraumatic cardiopulmonary resuscitation Abstract Air embolism is known to be a complicating factor in several clinical settings, including thoracic, cardiovascular, and neurosurgical operations; central line placement; and penetrating thoracic and cranial trauma. There are, however, only few case descriptions for cardiopulmonary resuscitation massive cerebral air embolism, and the frequency of this supposedly rare complication is unknown. Computed tomography is useful for showing cerebral air embolism. In this report, we present a 16-year-old adolescent girl with cerebrovascular air embolism on computed tomographic examination after a posttraumatic cardiopulmonary resuscitation and discuss the reasonable mechanisms of cerebrovascular air embolism. Cerebral air embolism (CAE) is not a rare condition. It can be caused by decompression disease or trauma or can occur iatrogenically [1]. Air embolism can develop following various clinical conditions such as thoracic, cardiovascular, and neurosurgical operations; hemodialysis; placement of central lines; and penetrating thoracic and cranial traumas. However, the volume of intravascular air is generally small in such embolies. Massive air embolism in major cerebral vessels is quite rare [2]. The accurate diagnosis of cerebrovascular air embolism is difficult and frequently is made in late stage or in necropsy. The aim of this article was to present the imaging findings of a traumatized adolescent with massive air embolism occurring during computed tomographic (CT) scanning while she was on cardiopulmonary resuscitation (CPR) and to discuss the case in the light of pertinent literature. A 16-year-old adolescent girl was severely head injured in a traffic accident. She was in cardiopulmonary arrest when she was brought to the emergency department by ambulance. She presented with dilated pupils, chest injury, and no cardiac activity. Cardiopulmonary resuscitation was immediately started. Computed tomography imaging of the cranium was carried out to check potential brain injury as the patient was still on CPR. During CT scanning, a sudden facial subcutaneous emphysema developed in the patient, followed by irreversible cardiopulmonary arrest (Fig. 1). The CT imaging demonstrated neither skull fracture nor extravascular pneumocephalus. The only positive finding was massive air in the cerebral arteries. Air was observed in bilateral internal carotid, bilateral external carotid, and vertebral arteries (Fig. 2). There was air in the internal carotid artery but no cervical trauma. Although systemic circulation was restored, the patient died 1 hour after admission. Cerebral air embolism may be caused by iatrogenic or traumatic introduction of air into the arterial or venous circulation. It may occur as a complication of angiography or via a peripheral or central venous line [3,4]. It may also occur in thoracic, cardiovascular, and 0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
neurosurgical surgeries; thoracic or cranial trauma; and during hemodialysis [5,6]. Computed tomographic scanning is the imaging modality used to show CAE [5]. However, CT demonstration of air in almost all the major cerebral arteries is extremely rare. It is assumed that air particles may enter the arterial circulation in 3 ways: by direct passage, by passage through shunts between main bronchi and pulmonary veins, and by passage through cardiac septal defects [7]. Hashimoto et al [8] have claimed that during artificial respiration, air passing through the traumatic shunts between main bronchi and pulmonary veins enters the heart and by external cardiac message is sent into intracerebral arteries. In our case, one of the mentioned mechanisms of CAE might have been involved. However, that the massive air embolization in all cerebral arteries in our case leads us to think that stepwise, the air first passed through the traumatic shunts during CPR, entered the heart and then general blood circulation and finally cerebral arteries. The massive CAE has a high rate of mortality. The diagnosis of cerebrovascular air embolism in a trauma patient is particularly difficult. Computed tomographic imaging is a very helpful and fast method used for diagnosis. In CT imaging, in light cases, air embolus is observed as small air particles, whereas in severe cases, as massive air filling the blood vessels. The distribution of intracranial air may depend on the quantity of air and the position of the patient. Because of massive air embolism in our patient, we observed a diffuse distribution of air in the anterior-posterior system. Traumas are among the primary causes of death in the first 4 decades of life, and 25% of deaths due to trauma are caused by chest trauma. Some of chest trauma patients may need CPR. In conclusion, although rare, one should consider the possible occurrence of massive air embolism during performing CPR on such patients.
Ramazan Buyukkaya Department of Radiology Duzce University, School of Medicine Duzce, Turkey E-mail address: [email protected] Ömer Aydın Bahattin Hakyemez Müfit Parlak Department of Radiology Uludag University, School of Medicine Bursa, Turkey http://dx.doi.org/10.1016/j.ajem.2013.09.020
194.e2
R. Buyukkaya et al. / American Journal of Emergency Medicine 32 (2014) 194.e1–194.e2
Fig. 1. Axial head CT in lung (A) and bone (B) windows demonstrates facial subcutaneous emphysema (*) and vascular structure (white arrows).
Fig. 2. A brain CT scan revealed cerebral air embolism, especially in the arterial-circulation territory.
References [1] Alper F, Kantarci M, Onbas O, Okur A, Ceviz N. Three-dimensional spiral CT reconstruction in a patient with massive cerebral air embolism. Emerg Radiol 2004;11:87e8. [2] Wijman CA, Kase CS, Jacobs AK, Whitehead RE. Cerebral air embolism as a cause of stroke during cardiac catheterization. Neurology 1998;51:318–9. [3] Rubinstein D, Symonds D. Gas in the cavernous sinus. AJNR Am J Neuroradiol 1994;15:561–6. [4] Takahashi W, Yoshii F, Ohsuga S, Izumi Y, Shinohara Y. Two patients with paradoxical cerebral air embolism due to accidental disconnection of a subclavian intravenous catheter. Jpn J Stroke 1995;17:89–94.
[5] Hwang TL, Fremaux R, Sears ES, et al. Confirmation of cerebral air embolism with computerized tomography. Ann Neurol 1993;13:214–5. [6] Nakao N, Moriwaki H, Oiwa Y. Barotraumatic cerebral air embolism following scuba diving. Brain Nerve 1990;42:1097–100. [7] Atalar MH, Oztoprak B, Erdinc P, Ozum U. Diffuse cerebrovascular air embolism on CT secondary to cardiopulmonary resuscitation. Turk J Trauma Emerg Surg 2007;13(4):319–21. [8] Hashimoto Y, Yamaki T, Sakakibara T, Matsui J, Matsui M. Cerebral air embolism caused by cardiopulmonary resuscitation after cardiopulmonary arrest on arrival. J Trauma 2000;48:975–7.
