Right Hemisphere Cerebral Infarction Due to Air Embolism from Percutaneous Lung Biopsy: A Case Report

doi:10.4236/ojrad.2013.33021

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Open Journal of Radiology, 2013, 3, 130-132

http://dx.doi.org/10.4236/ojrad.2013.33021 Published Online September 2013 (http://www.scirp.org/journal/ojrad)

Right Hemisphere Cerebr al Infarction Due to Air

Embolism from Percutaneous Lung Biopsy: A Case Report

Chaitanya Ahuja1*, Yama Kharoti1, Jeffery J. Critchfield2, Meghna Chadha2

1Dotter Institute, Oregon Health & Science University, Portland, USA

2Wayne State University, Detroit, USA

Email: *[email protected]

Received April 18, 2013; revised May 18, 2013; accepted May 25, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Percutaneous transthoracic needle biopsy is a common procedure in interventional radiology. Systemic arterial air em-

bolism causing cerebral infarction is a rare but much feared complication of percutaneous lung biopsy. We present a

comprehensive review of iatrogenic air embolism post-lung biopsy, a complication that is often sub optimally managed.

Patho-physiology, clinical features, and risk factors and management are reviewed.

Keywords: Air Embolism; Lung Biopsy; Cerebral Infarction; Computed Tomography (CT) Guidance

1. Introduction

A CT-guided need le lung biopsy is a common interven e-

tional radiology procedure. Percutaneous lung biopsy is

considered as a safe and effective method for obtaining a

tissue diagnosis in patients with lung masses. Reported

complications include pneumothorax, intrapulmonary he-

morrhage, hemoptysis, air embolism, seeding of the bi-

opsy tract, and death. The most common complication,

pneumothorax, is easily treated by radiologists and is

typically associated with no long-term sequela. Air em-

bolism as a complication is extremely rare; however it

can become fatal when it happens. Early diagnosis and

rapid application of hyperbaric oxygen therapy are the

mainstay of treatment.

2. Case Summary

An elderly gentleman with a known esophag eal mass and

multiple pulmonary nodules was referred for a CT

guided FNA biopsy of a pulmonary nodule. The patient

was placed in left lateral decubitus position on the CT

table. A 19 gauge needle was advanced under CT fluo-

roscopy into a righ t pulmonary nodule and FNA samples

were obtained in end inspiration (Figure 1). During the

procedure the patient became verbally unresponsive and

rapidly developed left sided hemiplegia. Subsequently, a

partial seizure was witnessed on the CT table. The pro-

cedure was concluded and a non contrast head CT was

obtained (Figure 2). The head CT showed gas within the

right MCA (Middle Cerebral Artery) territory vessels.

Hyperbaric oxygen therapy was initiated as per the insti-

tutional air embolism protocol. A subsequent brain MR

showed T2/FLAIR hyperintensity in the right MCA ter-

ritory along with diffusion restriction, compatible with

cerebral infarction (Figure 3). The patient developed

permanent disability as a result.

3. Discussion

Percutaneous lung biopsy is one of the most common

procedures performed in radiology departments. It is the

minimally invasive gold standard for the histopathologic

investigation of lung masses. Compared with other per-

cutaneous biopsy procedures, lung biopsy carries a higher

risk of potential complications, including occasional re-

ports of death. Very few case reports have been de-

scribed in literature relating to cerebral infarction due to

air embolism from percutaneous lung biopsy. The largest

series of four cases has been reported from Korea [1].

Though rare, air embolization from percutaneous lung

biopsy is a known and potentially devastating complica-

tion. Indeed, the few cases of death reported from this

procedure are most often due to air embolism. It can

cause subsequent myocardial infarction, intractable ar-

rhythmia or stroke [2]. The primary mechanism for in-

troduction of air embolism is the creation of an air-

way-pulmonary vessel fistula during the procedure [3].

Issues with technique, such as allowing the needle hub to

*Corresponding author.

C. AHUJA ET AL. 131

Figure 1. CT fluoroscopy image showing a percutaneous

lung biopsy.

(a)

(b)

(c)

Figure 2. Non-contrast axial head CT images at three dif-

ferent levels showing serpiginous air within the right MCA

territory distribution.

be open to outside air, can also result in air emboli.

There are three vessels that can receive air emboli

during a lung biopsy. Air can enter a branch of the pul-

monary arteries and lodge in the pulmonary capillary bed.

While this can interfere with gas exchange and decrease

pulmonary function locally, the lungs are well equipped

to handle such situ ation s v ia hyp oxic v aso cons triction [4 ].

Air emboli in a bronchial artery will also lodge in the

(a)

(b)

Figure 3. (a) Axial MR FLAIR image shows diffuse right

middle cerebral artery territory edema. (b) Diffusion

weighted image at the same level demonstrates increased

diffusion restriction in the same region, compatible with

cerebral infarction.

pulmonary capillary bed and have a similar net result.

However, the more dreaded result is air entering a pul-

monary vein, which flows into the left atrium and is

therefore a conduit to the systemic circulation.

Once in the systemic circulation, an air embolus can

lodge in any distal vessel. Emboli to either the coronary

or cerebral arteries tend to result in the most profound

morbidity [3,5]. In the case of the cerebral vasculature,

there is a predilection for emboli to lodge in the right

cerebral hemisphere [1]. Conventional aortic arch anat-

omy has the brachiocephalic artery as the first major

branch of the aorta. It is also the largest of the three

branches arising from the aortic arch. Further, the bra-

chiocephalic artery is normally in a straight line with the

trajectory of the ascending aorta. Air emboli therefore

tend to select this vessel due to both its caliber and tra-

jectory. Air then travels in a straight line through the

right common carotid and right internal carotid arteries,

ultimately lodging in the cerebral vasculature.

To prevent this catastrophic complication, multiple

strategies for decreasing the incidence of air emboli have

been discussed. Performing CT guided lung biopsies in

suspended expiration, as opposed to end inspiration, will

result in a higher intrathoracic pressure, which will de-

crease the likelihood of air emoblization. Higher gauge

C. AHUJA ET AL.

132

needles may also be used. In particular, FNA can be ef-

fectively done with a 21 or 22-gauge needle and will be

less likely to induce air embolism than a 19-gauge or

larger needle. Though diseased lung is often the target of

a biopsy, the more diseased lung a needle is passed

through, the greater the probability of inducing an air

embolism is [6].

Vigilance for air embolism during lung biopsy can

help decrease the most devastating complications, in-

cluding stroke and death. Recognition of air within the

left atrium, left ventricle or aorta is critical. Quickly

placing the patient in Trendelenburg’s position with their

right side down will keep the air from embolizing distally.

Interventional Radiology may then aspirate the air with

an intravascular catheter. In the event of distal air embo-

lism, hyperbaric oxygen therapy is the mainstay of ther-

apy [7].

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