A Ulucay

AJ Six

CC Wu

DH Hsi

ES Hoendermis

FW Verheugt

KH Ryu

MC Freund

PM Zee van der

RE Moon

T Hiraki

YF Wu

D. R. Smit

S. A. Kleijn

W. G. de Voogt

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CASE REPORTCoronary and cerebral air embolism: a rare complicationof computed tomography-guided transthoracic lung biopsyD. R. Smit & S. A. Kleijn &W. G. de VoogtPublished online: 10 April 2013# The Author(s) 2013. This article is published with open access at Springerlink.comCase reportA 71-year-old man with a history of excessive smokingwas evaluated for an abnormal chest X-ray. He had noangina and no risk factors for coronary artery disease.Considering a high probability of lung cancer in thispatient, computed tomography-guided transthoracic lungbiopsy was performed by an experienced radiologist. Aco-axial 18-gauge needle system was used to enter thelung and two core biopsy samples were obtained. Dur-ing the procedure the patient was asked to inhale inorder to reach the lesion. After the biopsy he developedmild haemoptysis followed by rapid loss of conscious-ness. After a couple of seconds the patient regainedconsciousness, was asymptomatic and did not showany signs of respiratory or haemodynamic complica-tions. However, the ECG showed ST-segment elevationin leads I, II, aVL, aVF and V3-6 without reciprocalST-segment depression suggestive of an acute myocar-dial infarction involving the distributions of more thanone coronary artery (Fig. 1c). Review of the multi-sliceCT images showed a mild pneumothorax, pulmonaryhaemorrhage, and air bubbles in both the circumflexcoronary artery and descending aorta, diagnostic of anair embolism of the arterial system (Fig. 1a, b). He wasplaced in a mild Trendelenburg position and was ad-ministered 100 % high-flow non-rebreathing oxygen.Anticoagulation therapy was not initiated due to thepulmonary haemorrhage. Electrocardiography showedcomplete resolution of the ST-segment elevation after20 min. However, 3 h later he developed seizures likelydue to air embolisation to the cerebral circulation. Asubsequent blood test showed cardiac troponin I eleva-tion of 11.0 μg/l, whereas echocardiography demonstrat-ed hypokinesis in the distal inferior and anteroseptalregions. The patient was eventually discharged after1 week without any cardiac, pulmonary or neurologicalsymptoms.DiscussionComputed tomography-guided transthoracic lung biopsyis a common clinical procedure for the diagnosis of abroad range of pulmonary pathological conditions. Mildself-limiting pneumothorax and pulmonary haemorrhageare common complications of this procedure. With in-cidences between 0.01 % and 0.21 %, the occurrence ofan air embolism in the left atrium, left ventricle, orsystemic circulation during a percutaneous core needlebiopsy of the lung is a rare, but potentially fatal com-plication [1]. The incidence might be underestimated bymissing systemic air embolisms in patients without car-diac or cerebral symptoms [2]. Freund et al. recentlyillustrated that although rare, radiological incidence of asystemic air embolism during a percutaneous core nee-dle biopsy of the lung was 3.8 % (23/610 patients),whereas the clinically apparent incidence was 0.49 %[1]. Our patient had a very unusual presentation ofmyocardial infarction and documented air embolisationin the coronary circulation and aorta with loss of con-sciousness possibly due to a cerebral air embolus. HeD. R. Smit (*)Department of Cardiology, VU University Medical Center, DeBoelelaan 1117,1081 HV, Amsterdam, the Netherlandse-mail: d.smit@vumc.nlS. A. KleijnDepartment of Internal Medicine, Sint Lucas Andreas Hospital,Amsterdam, the NetherlandsW. G. de VoogtDepartment of Cardiology, Sint Lucas Andreas Hospital,Amsterdam, the NetherlandsNeth Heart J (2013) 21:464–466DOI 10.1007/s12471-013-0411-1later experienced seizures due to an air embolus to the cerebralcirculation, although this could not be proven [3].The mechanism for air embolisation has been explained bytwo different mechanisms. First, when the tip of the biopsyneedle is lodged in a pulmonary vein, air embolisation canoccur with the removal of the inner stylet during rapid inspira-tion due to the atmospheric pressure exceeding the pulmonaryvenous pressure. Second, when a needle simultaneously trans-verses an air-containing space and adjacent pulmonary vein, afistula can occur and air will enter the vein when the alveolar airpressure is greater than the pulmonary venous pressure, forexample during coughing [4–6]. We did not treat the patientwith hyperbaric oxygen because the symptoms were transient.Trendelenburg position and 100%oxygen has had a favourableoutcome in other cases [4, 5, 7, 11]. Air embolisation has beendescribed to reduce perfusion distal to the obstruction as well asinduce an inflammatory response to the bubble [7]. There isevidence that heparin may be beneficial in the treatment of gasembolism [8]. We concluded that this was a self-limiting com-plication and did not administer heparin or other antiplatelettherapy due to the pulmonary haemorrhage [9–12].ConclusionOur case illustrates the possible fatal complication that due to itslow incidence is relatively underdiagnosed. Broader awarenessof this life-threatening complication of CT-guided lungbiopsy should allow fast initial recognition and manage-ment by interventional radiologists and cardiologists forimproved outcome.Funding None.Conflict of interests None declared.Open Access This article is distributed under the terms of the CreativeCommons Attribution License which permits any use, distribution, andreproduction in any medium, provided the original author(s) and thesource are credited.References1. Freund MC, Petersen J, Goder KC, et al. Systemic air embolismduring percutaneous core needle biopsy of the lung: frequency andrisk factors. BMC Pulm Med. 2012;12:2.2. Hiraki T, Fujiwara H, Sakurai J, et al. Nonfatal systemic air embolismcomplicating percutaneous CT-guided transthoracic needle biopsy:four cases from a single institution. Chest. 2007;132:684–90.3. Six AJ, Backus BE, Kingma A, et al. Consumption of diag-nostic procedures and other cardiology care in chest painpatients after presentation at the emergency department. NethHeart J. 2012;20:499–504.Fig. 1 a CT image shows a CT-guided transthoracic lung biopsywith the biopsy needle (whitearrow) entering the left lung. bCT image showing a mildpneumothorax (white arrow),pulmonary haemorrhage and airbubbles in both the circumflexcoronary artery and descendingaorta (black arrows). c ECGshowing marked ST-segmentelevation in leads I, II, aVL, aVFand V3-6Neth Heart J (2013) 21:464–466 4654. Wu CC, Maher MM, Shepard JA, et al. Complications ofCT-guided percutaneous needle biopsy of the chest: preven-tion and management. AJR Am J Roentgenol. 2011;196:678–82.5. Hsi DH, Thompson TN, Fruchter A, et al. Simultaneous coronaryand cerebral air embolism after CT-guided core needle biopsy ofthe lung. Tex Heart Inst J. 2008;35:472–4.6. Wu YF, Huang TW, Kao CC, et al. Air embolism complicatingcomputed tomography-guided core needle biopsy of the lung.Interact Cardiovasc Thorac Surg. 2012;14:771–2.7. Moon RE. Gas embolism. In: Oriani G, Marroni A, Wattel F,editors. Handbook on hyperbaric medicine. Milan: Springer;1996. p. 229–48.8. Ryu KH, Hindman BJ, Reasoner DK, et al. Heparin reduces neuro-logical impairment after cerebral arterial air embolism in the rabbit.Stroke. 1996;27:303–10.9. Verheugt FW. Antithrombotic therapy in heart failure. Neth HeartJ. 2012;20:176–8.10. van der Zee PM, Verberne HJ, Cornel JH, et al. GRACE and TIMIrisk scores but not stress imaging predict long-term cardiovascularfollow-up in patients with chest pain after a rule-out protocol. NethHeart J. 2011;19:324–30.11. Ulucay A, AksoyMF, Sahin E. Transthoracic echocardiography mayshow saddle pulmonary embolism. Neth Heart J. 2011;19:531.12. Hoendermis ES. Pulmonary arterial hypertension: an update. NethHeart J. 2011;19:514–22.466 Neth Heart J (2013) 21:464–466

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Coronary and cerebral air embolism: a rare complication of computed tomography-guided transthoracic lung biopsy

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Coronary and cerebral air embolism: a rare complication of computed tomography-guided transthoracic lung biopsy

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