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Brain & NeuroRehabilitation Nov 2023Cerebral air embolism (CAE) occurs in various clinical situations such as surgery, angiography, and hemodialysis; most are iatrogenic. Here we report the case of a...
Cerebral air embolism (CAE) occurs in various clinical situations such as surgery, angiography, and hemodialysis; most are iatrogenic. Here we report the case of a 57-year-old man who developed CAE immediately after air-powder abrasive treatment, which is commonly used in dentistry. The patient underwent air-powder abrasive treatment for peri-implantitis, and immediately after the treatment, cardiac arrest occurred and cardio- pulmonary resuscitation was performed. After resuscitation, brain computed tomography performed in the emergency room showed scattered dark density presumed to be air. The day after admission, the patient showed right hemiplegia and a multifocal cerebral infarction was observed on brain magnetic resonance imaging. Therefore, CAE was strongly suspected. After hyperbaric oxygen treatment (HBOT), which started 4 days after the incident, the patient regained consciousness and showed improvement in cognitive impairment, and only grade 4 muscle weakness was observed in the right lower extremity on the manual muscle test. This case highlights the importance of considering CAE as a possible cause of neurological symptoms occurring during clinical procedures involving air, and adds to the accumulation of evidence of therapeutic effects of delayed HBOT.
PubMed: 38047095
DOI: 10.12786/bn.2023.16.e22 -
European Journal of Radiology Jan 2024Cerebral arterial gas embolism (CAGE) occurs when air or medical gas enters the systemic circulation during invasive procedures and lodges in the cerebral vasculature....
PURPOSE
Cerebral arterial gas embolism (CAGE) occurs when air or medical gas enters the systemic circulation during invasive procedures and lodges in the cerebral vasculature. Non-contrast computer tomography (CT) may not always show intracerebral gas. CT perfusion (CTP) might be a useful adjunct for diagnosing CAGE in these patients.
METHODS
This is a retrospective single-center cohort study. We included patients who were diagnosed with iatrogenic CAGE and underwent CTP within 24 h after onset of symptoms between January 2016 and October 2022. All imaging studies were evaluated by two independent radiologists. CTP studies were scored semi-quantitatively for perfusion abnormalities (normal, minimal, moderate, severe) in the following parameters: cerebral blood flow, cerebral blood volume, time-to-drain and time-to-maximum.
RESULTS
Among 27 patient admitted with iatrogenic CAGE, 15 patients underwent CTP within the designated timeframe and were included for imaging analysis. CTP showed perfusion deficits in all patients except one. The affected areas on CTP scans were in general located bilaterally and frontoparietally. The typical pattern of CTP abnormalities in these areas was hypoperfusion with an increased time-to-drain and time-to-maximum, and a corresponding minimal decrease in cerebral blood flow. Cerebral blood volume was mostly unaffected.
CONCLUSION
CTP may show specific perfusion defects in patients with a clinical diagnosis of CAGE. This suggests that CTP may be supportive in diagnosing CAGE in cases where no intracerebral gas is seen on non-contrast CT.
Topics: Humans; Retrospective Studies; Tomography, X-Ray Computed; Embolism, Air; Cohort Studies; Perfusion; Iatrogenic Disease; Perfusion Imaging; Cerebrovascular Circulation; Stroke; Brain Ischemia
PubMed: 38043382
DOI: 10.1016/j.ejrad.2023.111242 -
Frontiers in Pediatrics 2023Pediatric liver transplantation is an important modality for treating biliary atresia. The overall survival rate of pediatric liver transplantation has significantly...
BACKGROUND
Pediatric liver transplantation is an important modality for treating biliary atresia. The overall survival rate of pediatric liver transplantation has significantly improved. The incidence of perioperative cardiac events was evaluated, and risk factors were also investigated in adult patients undergoing liver transplantation in previous studies. To the best of our knowledge, this is the first case of a cardiac event during a pediatric living-donor liver transplantation.
CASE SUMMARY
Our report describes the management of cardiac events during a liver transplantation in a 7-month-old girl. The ST segment began to increase to 3.0 mm immediately after reperfusion, with peak ST-segment elevation reaching 13.2 mm after 45 min. The procedure ended uneventfully after continuous symptomatic and etiological treatment. It was considered to be the occurrence of an acute air embolism complication during the procedure based on the electrocardiograph and biomarkers. An echocardiogram during follow-up showed a patent foramen ovale with a left-to-right shunt tract width of 2.7 mm.
DISCUSSION
Pediatric liver transplantation has become a state-of-the-art treatment for children with end-stage liver disease and can improve the quality of life to some extent. These children may be complicated with congenital heart disease, which increases the risk of surgery. Application of echocardiogram, close monitoring, and appropriate management may reduce the incidence of perioperative cardiac events.
PubMed: 38034826
DOI: 10.3389/fped.2023.1271925 -
Revista Espanola de Enfermedades... Nov 2023A 63-year-old man presented to emergency department with a 2-hour history of chest tightness and suffocation. The oxygen saturation was 50% while he was breathing...
A 63-year-old man presented to emergency department with a 2-hour history of chest tightness and suffocation. The oxygen saturation was 50% while he was breathing ambient air. Laboratory evaluation revealed D2 polymer level, 0.69 mg/L (reference range, 0 to 0.50), activated partial thromboplastin time, 75.0 s (reference range, 28.0 to 43.5). Computed tomography angiography of the chest showed thrombus in the right pulmonary artery, inferior vena cava and right atrium. Coronal view also demonstrated a hepatic mass with a massive neovascularization, extending from hepatic veins into the inferior vena cava.
PubMed: 38031905
DOI: 10.17235/reed.2023.10113/2023 -
BMC Emergency Medicine Nov 2023The aim of this trial-based economic evaluation was to assess the incremental costs and cost-effectiveness of the modified diagnostic strategy combining the YEARS rule... (Randomized Controlled Trial)
Randomized Controlled Trial
Cost-effectiveness of modified diagnostic strategy to safely rule-out pulmonary embolism in the emergency department: a non-inferiority cluster crossover randomized trial (MODIGLIA-NI).
BACKGROUND
The aim of this trial-based economic evaluation was to assess the incremental costs and cost-effectiveness of the modified diagnostic strategy combining the YEARS rule and age-adjusted D-dimer threshold compared with the control (which used the age-adjusted D-dimer threshold only) for the diagnosis of pulmonary embolism (PE) in the Emergency Department (ED).
METHODS
Economic evaluation from a healthcare system perspective alongside a non-inferiority, crossover, and cluster-randomized trial conducted in 16 EDs in France and two in Spain with three months of follow-up. The primary endpoint was the additional cost of a patient without failure of the diagnostic strategy, defined as venous thromboembolism (VTE) diagnosis at 3months after exclusion of PE during the initial ED visit. Mean differences in 3-month failure and costs were estimated using separate generalized linear-regression mixed models, adjusted for strategy type, period, and the interaction between strategy and period as fixed effects and the hospital as a random effect. The incremental cost-effectiveness ratio (ICER) was obtained by dividing the incremental costs by the incremental frequency of VTE.
RESULTS
Of the 1,414 included patients, 1,217 (86%) were analyzed in the per-protocol analysis (648 in the intervention group and 623 in the control group). At three months, there were no statistically significant differences in total costs (€-46; 95% CI: €-93 to €0.2), and the failure rate was non inferior in the intervention group (-0.64%, one-sided 97.5% CI: -∞ to 0.21%, non-inferiority margin 1.5%) between groups. The point estimate of the incremental cost-effectiveness ratio (ICER) indicating that each undetected VTE averted in the intervention group is associated with cost savings of €7,142 in comparison with the control group. There was a 93% probability that the intervention was dominant. Similar results were found in the as randomized population.
CONCLUSIONS
Given the observed cost decrease of borderline significance, and according to the 95% confidence ellipses, the intervention strategy has a potential to lead to cost savings as a result of a reduction in the use of chest imaging and of the number of undetected VTE averted. Policy-makers should investigate how these monetary benefits can be distributed across stakeholders.
CLINICALTRIALS
Trial registration number ClinicalTrials.gov Identifier: NCT04032769; July 25, 2019.
Topics: Humans; Venous Thromboembolism; Cost-Benefit Analysis; Pulmonary Embolism; Emergency Service, Hospital; France
PubMed: 38030975
DOI: 10.1186/s12873-023-00910-x -
Korean Journal of Anesthesiology Apr 2024Esophagogastroduodenoscopy (EGD) is vital for the diagnosis and treatment of various gastrointestinal conditions but carries a low risk of venous air embolism (VAE). We...
BACKGROUND
Esophagogastroduodenoscopy (EGD) is vital for the diagnosis and treatment of various gastrointestinal conditions but carries a low risk of venous air embolism (VAE). We report a case of VAE during EGD, confirmed by computed tomographic pulmonary angiography (CTPA).
CASE
A 56-year-old male with a history of hypopharyngeal cancer underwent EGD for dysphagia-related esophageal dilation. Signs of VAE were noted, prompting swift interventions, including oxygen therapy, positional changes, and CTPA. CTPA revealed the Mercedes-Benz sign, pneumomediastinum, and a minimal pneumothorax. The patient's oxygen saturation improved within 30 min before undergoing CTPA, and he was discharged on postoperative day 4.
CONCLUSIONS
Timely recognition of VAE, resulting in appropriate interventions supported by CTPA, resulted in favorable patient outcomes.
Topics: Male; Humans; Middle Aged; Pulmonary Embolism; Esophagoscopy; Embolism, Air; Angiography
PubMed: 38029795
DOI: 10.4097/kja.23722 -
Clinical Case Reports Nov 2023The coronavirus disease 2019 (COVID-19) pandemic is responsible for huge morbidity and mortality throughout the world. Several serious complications of this disease have...
The coronavirus disease 2019 (COVID-19) pandemic is responsible for huge morbidity and mortality throughout the world. Several serious complications of this disease have been reported. It can cause hypercoagulability, which may lead to venous and arterial thromboembolic diseases. This hypercoagulability state is also associated with high morbidity and mortality. Arterial thrombosis in COVID-19 is poorly described compared to venous thrombosis and pulmonary embolism. We report a case of an extensive arterial thrombosis leading to a limb ischemia with extremely high D-dimer in a COVID-19 patient. A 69-year-old man was hospitalized for febrile dyspnea. He is a hypertensive and diabetic patient. On admission, pulse oxygen saturation was 72% on room air. He had cyanosis of the left foot up to the mid-thigh. The left pedal, posterior tibial, popliteal and femoral pulses were abolished. Chest CT scan was in favor of COVID-19. He has a high D-dimer level of 257,344 ng/mL. Arterial Echo-Doppler found an extensive intraluminal thrombus along the arterial axes of the left lower limb, completely obstructing them, starting from the primitive iliac artery just after its bifurcation with the aorta, and extending distally (external iliac; common femoral; superficial femoral; popliteal; anterior tibial; posterior tibial; fibular and pedal). The patient was diagnosed with COVID-19 critical form, associated with ischemia of the left lower limb secondary to an extensive arterial thrombosis. He was receiving anticoagulation, and underwent surgical amputation of the ischemic limb. The patient survived the event; however, he was on long-term oxygen therapy at home. Arterial thrombosis may occur during COVID-19 and may be responsible for peripheral or central ischemia aggravating morbidity and mortality. The occurrence of these events is related to the D-dimer value. Anticoagulation is an important part of the management of COVID-19, especially in severe forms in order to limit the occurrence of these thromboembolic diseases.
PubMed: 38028042
DOI: 10.1002/ccr3.8231 -
Insights Into Imaging Nov 2023To evaluate the effect of tract embolization (TE) with gelatin sponge slurries during a percutaneous lung biopsy on chest tube placement and to evaluate the predictive...
BACKGROUND
To evaluate the effect of tract embolization (TE) with gelatin sponge slurries during a percutaneous lung biopsy on chest tube placement and to evaluate the predictive factors of chest tube placement.
METHODS
Percutaneous CT-guided lung biopsies performed with (TE) or without (non-TE) tract embolization or between June 2012 and December 2021 at three referral tertiary centers were retrospectively analyzed. The exclusion criteria were mediastinal biopsies, pleural tumors, and tumors adjacent to the pleura without pleural crossing. Variables related to patients, tumors, and procedures were collected. Univariable and multivariable analyses were performed to determine risk factors for chest tube placement. Furthermore, the propensity score matching analysis was adopted to yield a matched cohort.
RESULTS
A total of 1157 procedures in 1157 patients were analyzed, among which 560 (48.4%) were with TE (mean age 66.5 ± 9.2, 584 men). The rates of pneumothorax (44.9% vs. 26.1%, respectively; p < 0.001) and chest tube placement (4.8% vs. 2.3%, respectively; p < 0.001) were significantly higher in the non-TE group than in the TE group. No non-targeted embolization or systemic air embolism occurred. In the whole population, two protective factors for chest tube placement were found in univariate analysis: TE (OR 0.465 [0.239-0.904], p < 0.05) and prone position (OR 0.212 [0.094-0.482], p < 0.001). These data were confirmed in multivariate analysis (p < 0.001 and p < 0.0001 respectively). In the propensity matched cohort, TE reduces significatively the risk of chest tube insertion (OR = 0.44 [0.21-0.87], p < 0.05).
CONCLUSIONS
The TE technique using standardized gelatin sponge slurry reduces the need for chest tube placement after percutaneous CT-guided lung biopsy.
CRITICAL RELEVANCE STATEMENT
The tract embolization technique using standardized gelatin sponge slurry reduces the need for chest tube placement after percutaneous CT-guided lung biopsy.
KEY POINTS
1. Use of tract embolization with gelatine sponge slurry during percutaneous lung biopsy is safe. 2. Use of tract embolization significantly reduces the risk of chest tube insertion. 3. This is the first multicenter study to show the protective effect of tract embolization on chest tube insertion.
PubMed: 38015340
DOI: 10.1186/s13244-023-01566-8 -
Journal of Stroke and Cerebrovascular... Jan 2024Although most stroke patients have underlying vascular risk factors, it is important to consider infectious causes of stroke in young adults without traditional risk...
BACKGROUND
Although most stroke patients have underlying vascular risk factors, it is important to consider infectious causes of stroke in young adults without traditional risk factors or patients with cryptogenic stroke. Pulmonary vein thrombosis and air embolism can potentially cause cerebral infarction. However, the association between infection and pulmonary vein thrombosis or air embolism is often overlooked. In this case, we present a rare infectious cause of stroke and air embolism involving a pulmonary abscess and pulmonary vein thrombosis.
CASE PRESENTATION
A 37-year-old male patient initially presented with right-sided pneumonia. During treatment at a local hospital, he developed headaches and left limb weakness. Subsequently, he was transferred to our hospital due to septic shock. Neurological evaluations revealed multiple brain foci and thrombosis in the right superior pulmonary vein. Following treatment with broad-spectrum antibiotics and anticoagulants, the patient's clinical symptoms and inflammatory markers showed improvement. However, a computed tomography scan revealed the formation of a pulmonary abscess, and the patient experienced coma and epilepsy after severe coughing with massive hemoptysis. Multiple air embolisms were observed in the brain computed tomography. Eventually, the patient's family chose to discharge him from the hospital.
CONCLUSIONS
This case highlights the rare and complex etiologies of stroke associated with infection in a young patient. Early detection, diagnosis, and appropriate treatment of infected systemic embolism in young patients are crucial to prevent serious complications.
Topics: Humans; Male; Young Adult; Adult; Lung Abscess; Pulmonary Veins; Embolism, Air; Venous Thrombosis; Stroke; Pulmonary Embolism
PubMed: 38000110
DOI: 10.1016/j.jstrokecerebrovasdis.2023.107461 -
International Journal of Surgery Case... Dec 2023Traumatic embolization of pellets into the cerebral circulation is a rare complication following gunshot wounds to the neck, chest and abdomen. Foreign bodies enter the...
Air rifle wound to the chest and pellet embolism to the intracranial internal carotid artery with a middle cerebral artery territory infarct: A case report and review of literature.
INTRODUCTION
Traumatic embolization of pellets into the cerebral circulation is a rare complication following gunshot wounds to the neck, chest and abdomen. Foreign bodies enter the circulation from early direct puncture or delayed erosion of an artery or vein or directly through the heart.
PRESENTATION OF CASE
A previously well 13-year-old Sri Lankan boy who presented 2 h following an air rifle injury to the lower sternum with chest pain, developed seizures and left hemiparesis. Contrast CT angiogram showed the pellet at the base of the skull at the right carotid canal, with a middle cerebral artery (MCA) thrombus and evidence of MCA infarction. Decompressive craniectomy was performed. Cerebral angiography confirmed complete occlusion of the intracranial internal carotid artery (ICA) by the pellet, without cross circulation from the left ICA. Attempts at endovascular pellet retrieval failed. Open pellet embolectomy was not performed and the patient was managed conservatively.
DISCUSSION & CONCLUSION
Air rifle injury to the chest causing pellet embolism from the left ventricle to the right intracranial ICA with associated right MCA thrombus is a rare phenomenon. Missile embolism must be suspected when neurological findings are not in concordance with the site of injury especially in the absence of an exit wound and an inability to locate the pellet in the vicinity of the entry wound. Radiographs, CT and cerebral angiography are indicated to locate the pellet and associated injuries. The decision on surgical embolectomy, endovascular retrieval or expectant management is an individualized decision dependent on many factors.
PubMed: 37992670
DOI: 10.1016/j.ijscr.2023.109076