DOI:10.2214/AJR.05.1481
AJR 2006; 187:W242-W243
© American Roentgen Ray Society
Systemic Air Embolism Complicating Percutaneous Transthoracic Needle Biopsy
Antoine Khalil,
Hélène Prigent,
Antoine Parrot and
Marie-France Carette
AP-HP, Tenon Hospital Paris, France
A 53-year-old woman was admitted for exploration of persistent left lower
lobe excavated opacity despite 3 weeks of antibiotic therapy. Bronchoscopy
results were negative, and a diagnostic CT-guided transthoracic biopsy was
performed. A 20-gauge coaxial system was inserted into the cavity wall with
the patient in the prone position. After the first biopsy, the patient
complained of a painful sensation of electrical current in the legs followed
by several episodes of unconsciousness with flaccidity. The control CT scan
showed air in the pulmonary vein, the left atrium, and the left ventricle
(Figs. 10A and
10B). The air volume in the
cardiac cavities was calculated as 24 mL.
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Fig. 10A —53-year-old woman with systemic air embolism complicating
transthoracic needle biopsy. Control CT scan with patient in prone position
shows needle biopsy tip (arrowheads) in cavity wall and air embolus
in ventricle lumen (arrow).
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Fig. 10B —53-year-old woman with systemic air embolism complicating
transthoracic needle biopsy. Control CT scan from same volume acquisition as
A shows air embolus in pulmonary veins (arrowheads) draining
into left atrium (arrow).
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The procedure was interrupted and the needle removed. During the next 5
minutes, the patient presented consciousness fluctuations but was not moved to
avoid additional migration of air bubbles. Ten minutes after the final control
CT scan, a new volume acquisition focused on the heart cavities was performed
without ECG gating and showed a complete disappearance of air in the left
cardiac cavities (Fig. 10C).
The results of a brain CT scan were normal.
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Fig. 10C —53-year-old woman with systemic air embolism complicating
transthoracic needle biopsy. Final control CT scan, 10 minutes after previous
control, shows complete disappearance of air in left cardiac cavities.
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The patient was then turned to a supine and Trendelenburg position. Her
neurologic condition completely normalized, and she was transferred to the
hyperbaric oxygen chamber within 2 hours of the event, where she received
hyperbaric oxygen therapy for 105 minutes at 105 x 103 Pa.
Twenty-four hours later, brain MRI with diffusion-weighted imaging was
performed. The results were normal, and the CT-guided biopsy was not
diagnostic. Thoracotomy showed pleural nodules resulting from
adenocarcinoma.
Symptomatic systemic air embolism is a rare but severe complication of
transthoracic needle biopsy. This case is the first time it has occurred in
our experience of 900 procedures (0.11%). The clinical presentation is similar
to thromboembolic stroke syndrome, ranging from focal neurologic deficits of
rapid onset such as hemiplegia, confusion, or convulsions to collapse and
death [1,
2]. Coronary artery symptoms
such as dysrhythmias or myocardial ischemia can be observed
[3].
The electrical current sensation in the legs can result from air embolism
into spinal cord arteries. These arteries arise in the thoracic-lumbar area
from intercostal or lumbar arteries, which themselves come from the posterior
and posterolateral aorta wall. Thus, air embolism can occur in these arteries
when the patient is in the prone position. The consciousness fluctuation is
related to brain air embolism and for that it is usually proposed to put the
head down; however a review of the literature by Muth and Shank
[4] indicates that a
horizontal, supine position is preferable for treatment of air embolism. In
addition, the head-down position may aggravate the cerebral edema that
develops in these patients. Furthermore, in our institution, we wait before
mobilizing the patient to allow a complete resolution of air from the cardiac
cavities to prevent a massive recurrent air embolism.
Radiologists must be aware of this extremely rare but potentially severe
complication so they can provide accurate diagnosis and treatment. It should
be suspected in patients presenting any neurologic symptoms during a
procedure. In such cases, we think that a heart CT scan should be performed
before moving the patient.
References
- Arnold BW, Zwiebel WJ. Percutaneous transthoracic needle biopsy
complicated by air embolism. AJR 2002;178
: 1400-1402[Free Full Text]
- Ashizawa K, Watanabe H, Morooka H, Hayashi K. Hyperbaric oxygen
therapy for air embolism complicating CT-guided needle biopsy of the lung.
AJR 2004; 182:1606
-1607[Free Full Text]
- Mansour A, AbdelRaouf S, Qandeel M, Swaidan M. Acute coronary
artery air embolism following CT-guided lung biopsy. Cardiovasc
Intervent Radiol 2005; 28:131
-134[CrossRef][Medline]
- Muth CM, Shank ES. Gas embolism. N Engl J
Med 2000; 342:476
-482[Free Full Text]
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