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Nagasaki University Nagasaki 852-8501, Japan
A 65-year-old woman was transferred to our hospital for the treatment of cryptococcal meningitis. She was treated with antifungal agents and recovered. Abnormal opacities were noted on her chest radiograph. A CT scan showed multiple nodular opacities in the upper and middle lobes. Although pulmonary cryptococcosis was suspected clinically, CT-guided lung biopsy was requested from pulmonologists to establish the diagnosis.
Under CT guidance with the patient in supine position, percutaneous biopsy was performed with a 15-cm 18-gauge cutting needle (Fine Core, Toray) during a single inspiratory breath-hold. A CT scan showed that the needle was placed into the lesion (Fig. 4A). Although the patient had been instructed to avoid coughing during this procedure, she coughed once. At the end of the procedure, before the removal of the needle, the patient again coughed and had a small amount of hemoptysis. She abruptly became unresponsive, pulseless, and hypotensive. She was immediately treated with oxygenation, steroids, and a vasopressor agent while she was in a supine position. Her heart rate and blood pressure returned to normal, but she did not become alert. Cranial CT performed immediately showed small air bubbles in the right middle cerebral arteries (Fig. 4B). A careful review of the CT scan, obtained to verify needle position, showed an air–fluid level in the ascending aorta and air in the right coronary artery (Figs. 4A and 4C).
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The patient was transferred to the hyperbaric oxygen chamber within 40 min of the event. She received hyperbaric oxygen therapy for 111 min at 181.8 x 103 Pa. Complete regression of consciousness was noted in 15 min after the initiation of the therapy. Diffusion-weighted cranial MR images obtained 1 day after the event showed small cortical infarctions in the area of the right middle cerebral artery (Fig. 4D). The patient had myoclonus for 1 day but eventually recovered without any neurologic deficit. The pathologic examination revealed pulmonary cryptococcosis.
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Percutaneous transthoracic needle biopsy has become a widely accepted diagnostic procedure for evaluating lung lesions. Systemic air embolism is a rare but potentially fatal complication after needle lung biopsy (incidence, 0.07%) [1]. Only 12 documented cases of this complication have been described in the English-language literature. To our knowledge, this is the first case of CT revealing air simultaneously in the coronary and cerebral arteries.
Treatment of systemic air embolism consists of supplying 100% oxygen, routine supportive measures such as steroids and anticonvulsant therapy, and placing the patient in the Trendelenburg and right lateral decubitus position [2]. A recent review of the literature indicates that a supine position of the patient is recommended for treatment of arterial air embolism [3]. Hyperbaric oxygen therapy is currently regarded as the mainstay of therapy [3, 4]. It reduces the bubble size, subsequently removes the occlusive bubble, and causes less endothelial damage. According to published case reports, four of five patients with hyperbaric oxygen therapy recovered, but four of seven patients without this therapy died.
In conclusion, radiologists should be aware of this rare complication and should be familiar with prompt and appropriate management for it. Immediate transfer to a hyperbaric oxygen chamber is required because the recovery depends on early recognition of the complication and prompt application of this therapy.
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