Cerebral air embolism treated using hyperbaric oxygen therapy

Article information

J Neurocrit Care. 2019;12(1):64-65
Publication date (electronic) : 2019 June 19
doi : https://doi.org/10.18700/jnc.190085
Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
Corresponding Author Sang-Beom Jeon, MD, PhD Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea Tel: +82-2-3010-3440 Fax: +82-2-474-4691 E-mail: sbjeonmd@gmail.com
Received 2019 May 17; Revised 2019 May 30; Accepted 2019 May 31.

A 59-year-old man underwent endoscopic balloon dilation for esophageal stricture. Upon the completion of the procedure, he was observed to be stuporous and quadriplegic. Computed tomography (CT) of the brain revealed multiple air emboli (Fig. 1A). Magnetic resonance imaging (MRI) performed 45 minutes after symptom onset revealed multiple lesions showing signal loss on susceptibility-weighted imaging, high signal intensity on diffusion-weighted imaging, and diffuse enhancement on T1-weighted contrast-enhanced imaging, which were compatible with air emboli, hyperacute infarcts, and a disrupted blood-brain barrier, respectively (Fig. 1B-1D). Hyperbaric oxygen therapy (HBOT) was administered 80 minutes after MRI (targeting 3.0 atmospheric pressure for 2 hours). Follow-up CT performed 80 minutes after HBOT revealed disappearance of the air emboli (Fig. 1E). Follow-up MRI performed 5 days after HBOT also revealed a decrease in the resolution of previously documented findings (Fig. 1F-1H). Most of his neurological symptoms improved, except mild left hemiparesis.

Fig. 1.

Computed tomography (CT) and magnetic resonance imaging (MRI) scans of the brain obtained before (upper row) and after (lower row) hyperbaric oxygen therapy (HBOT). (A) Initial CT scan showing multiple air emboli, predominantly in the right hemisphere. (B) Initial MRI scan showing multiple air emboli on susceptibility-weighted imaging, (C) acute infarcts on diffusion-weighted imaging, and (D) diffuse enhancement on T1-weighted contrast-enhanced imaging. The Glasgow Coma Scale score was 5 (eye opening, 2; motor response, 2; and verbal response, 1) when the initial MRI scan was obtained. (E) Follow-up CT scan obtained 80 minutes after HBOT showing disappearance of air emboli. (F) Follow-up MRI scan obtained 5 days after HBOT showing disappearance of air emboli on susceptibility-weighted imaging, (G) decrease in infarct size on diffusion-weighted imaging, and (H) resolution of diffuse enhancement on T1-weighted contrast-enhanced imaging. The Glasgow Coma Scale score was 14 (eye opening: 4, motor response: 6, and verbal response: 4) when the follow-up MRI scan was obtained. White arrows indicate air emboli, black arrows indicate acute infarcts, and white arrowheads indicate diffuse T1-enhancement.

This case indicates that MRI is a useful modality in diagnosing cerebral air embolism by documenting air emboli, hyperacute infarcts, and disruption of the blood–brain barrier [1-3]. HBOT may accelerate the disappearance of air emboli and promote the early resolution of ischemic lesions and reversal of the disrupted blood–brain barrier [4].

Notes

Conflict of interest

No potential conflict of interest relevant to this article.

Funding

This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number : HI18C1487).

Author contributions

Conceptualization: YJK and SBJ. Data curation & Formal analysis: YJK and SBJ. Visualization & Writing–original draft: YJK and SBJ. Writing–review editing: YJK and SBJ.

References

1. Jeon SB, Kim JS, Lee DK, Kang DW, Kwon SU. Clinicoradiological characteristics of cerebral air embolism. Cerebrovasc Dis 2007;23:459–62.
2. Jeon SB, Kang DW. Cerebral air emboli on T2-weighted gradient-echo magnetic resonance imaging. J Neurol Neurosurg Psychiatry 2007;78:871.
3. Hjouj M, Last D, Guez D, Daniels D, Sharabi S, Lavee J, et al. MRI study on reversible and irreversible electroporation induced blood brain barrier disruption. PLoS One 2012;7e42817.
4. Gill AL, Bell CN. Hyperbaric oxygen: its uses, mechanisms of action and outcomes. QJM 2004;97:385–95.

Article information Continued

Fig. 1.

Computed tomography (CT) and magnetic resonance imaging (MRI) scans of the brain obtained before (upper row) and after (lower row) hyperbaric oxygen therapy (HBOT). (A) Initial CT scan showing multiple air emboli, predominantly in the right hemisphere. (B) Initial MRI scan showing multiple air emboli on susceptibility-weighted imaging, (C) acute infarcts on diffusion-weighted imaging, and (D) diffuse enhancement on T1-weighted contrast-enhanced imaging. The Glasgow Coma Scale score was 5 (eye opening, 2; motor response, 2; and verbal response, 1) when the initial MRI scan was obtained. (E) Follow-up CT scan obtained 80 minutes after HBOT showing disappearance of air emboli. (F) Follow-up MRI scan obtained 5 days after HBOT showing disappearance of air emboli on susceptibility-weighted imaging, (G) decrease in infarct size on diffusion-weighted imaging, and (H) resolution of diffuse enhancement on T1-weighted contrast-enhanced imaging. The Glasgow Coma Scale score was 14 (eye opening: 4, motor response: 6, and verbal response: 4) when the follow-up MRI scan was obtained. White arrows indicate air emboli, black arrows indicate acute infarcts, and white arrowheads indicate diffuse T1-enhancement.