Clin Endosc.  2016 Mar;49(2):191-196. 10.5946/ce.2015.071.

Two Cases of Cerebral Air Embolism That Occurred during Esophageal Ballooning and Endoscopic Retrograde Cholangiopancreatography

• Park S
• Ahn JY
• Ahn YE
• Jeon SB
• Lee SS
• Jung HY
• Kim JH

• KMID: 2165045
• DOI: http://doi.org/10.5946/ce.2015.071

Abstract

Cerebral air embolism is an extremely rare complication of endoscopic procedure and often life threatening. We present two cases of cerebral infarction due to air embolization caused by an endoscopic intervention. The first case occurred during esophageal balloon dilatation for the treatment of a stricture of an anastomosis site in a 59-year-old man and the second case occurred during endoscopic papillary balloon dilatation in a 69-year-old man who had distal common bile duct stones. After the procedure, cardiopulmonary instability and altered mental status were observed in both patients, and cerebral air embolism was diagnosed in both cases. Hyperbaric oxygen therapy was started in the first case, and high FiO2 therapy was applied in the second case. Although this complication is rare, patient outcomes can be improved if physicians are aware of this potential complication, and immediately begin proper management.

Keyword

Intracranial embolism; Embolism, air; Endoscopy

MeSH Terms

Aged
Cerebral Infarction
Cholangiopancreatography, Endoscopic Retrograde*
Common Bile Duct
Constriction, Pathologic
Dilatation
Embolism, Air*
Endoscopy
Humans
Hyperbaric Oxygenation
Intracranial Embolism
Middle Aged

Figure

• 

  Fig. 1. Endoscopic procedures for the study patients. (A, B) Through-the-scope balloon dilatation was performed in case 1, and (C, D) endoscopic retrograde papillary drainage in case 2. (A) An initial esophagogastroduodenoscopy showed an esophageal stricture at the esophagojejunostomy anastomotic ring. (B) Through-the-scope balloon dilatation was performed. (C) Endoscopic biliary cannulation was carried out through the major papilla. (D) Endoscopic retrograde papillary drainage with ballooning was performed.

• 

  Fig. 2. Imaging studies with computed tomography (CT) and magnetic resonance imaging (MRI). (A) CT scan showing hypodense lesions indicative of air bubbles that were seen predominantly in the right hemisphere in case 1 (arrow). (B) Diffusion-weighted imaging showing diffusion restriction in the right hemisphere in case 1 (arrow). (C) MRI scan showing multiple wedge-shaped low-density regions in the right hemisphere in case 2 (arrow). (D) MRI scan showing multiple diffusion-restricted lesions and fluid-attenuated inversion recovery changes in case 2 (arrow).

• 

  Fig. 3. Endoscopic retrograde cholangiography showing extensive air in the portal vein in case 2 (arrow).

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