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Paradoxical Cerebral Air Embolism in a Young Hemodialysis Patient
Critical Care SESSION TITLE: Nervous System Disorders in the ICU 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM
Paradoxical Cerebral Air Embolism in a Young Hemodialysis Patient Frances Puello* Janine Harewood Sheelan Karim Olumayowa Abe and Samarth Beri New York-Presbyterian/Queens, Flushing, NY INTRODUCTION: Paradoxical Cerebral Air embolism (PCAE) is a rare, under diagnosed cause of stroke that can be associated with manipulation of central venous catheters (CVC). CASE PRESENTATION: A 37 year-old woman with a history of Systemic Lupus Erythematosus (SLE), seizures and end stage renal disease presented after a hypotensive seizure episode, following a dialysis session via a CVC. She was alert with left sided hemiplegia and left sided homonymous hemianopsia in emergency department. Her National Institutes of Health Stroke Scale score was 14. Initial head CT revealed diffuse hypodensities along the right frontal, parietal, and occipital lobes sulci, suggestive of fat or air embolus versus artifact. A repeat head CT scan 4 hours later revealed no abnormalities, so initial findings considered artifactual. CT angiogram and brain MRI showed no abnormalities. Patient then admitted for seizures with Todd’s paralysis. Her mental status progressively declined with persistent neurological deficits and patient was transferred to the MICU. Repeat MRI showed extensive right hemispheric cortical and subcortical abnormality with diffusion restriction. SLE cerebritis was considered, and serological tests obtained. No lab markers were consistent with SLE cerebritis. A lumbar puncture was performed, but cerebral fluid analysis was unrevealing for an infectious process. Extensive reviews with neuroradiology suggested the presence of a cerebral air embolism as a potential complication of her dialysis catheter. A contrast enhanced transthoracic echocardiogram confirmed the presence of a patent foramen ovale as a potential nidus for our theory. As a result, she was transferred for therapy with hyperbaric oxygen.
CONCLUSIONS: A high degree of suspicion in patients presenting with neurological abnormalities after HD for PCAE is required as early treatment is essential to reducing morbidity and mortality of this complication. Reference #1: Murphy B, Harford F, Cramer F. Cerebral air embolism resulting from invasive medical procedures. Treatment with hyperbaric oxygen. AnnSurg.1985;201:242-5 DISCLOSURE: The following authors have nothing to disclose: Frances Puello, Janine Harewood, Sheelan Karim, Olumayowa Abe, Samarth Beri No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.383
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
chestjournal.org
357A
CRITICAL CARE
DISCUSSION: PCAE is a potentially catastrophic event. The diagnosis should be entertained when a sudden neurological deterioration along with hemodynamic instability occurs in the setting of manipulation of a CVC. In this case, the diagnosis was delayed due to apparent resolution of the initial CT scan findings. It has been reported that CT findings of CAE can become negative 2.5 hours after the event occurred, thus a high index of suspicion should be maintained despite negative imaging. Currently hyperbaric oxygen is the treatment of choice. Studies have shown that initiation of hyperbaric oxygen within 8 hours of onset is associated with improved neurological outcomes. In a study of 16 subjects treated with hyperbaric oxygen, 8 patients recovered completely, while 5 patients saw partial improvement. The remaining 3 participants saw no improvement. No other treatment has demonstrated mortality benefit.
Paradoxical Cerebral Air Embolism in a Young Hemodialysis Patient Frances Puello* Janine Harewood Sheelan Karim Olumayowa Abe and Samarth Beri New York-Presbyterian/Queens, Flushing, NY INTRODUCTION: Paradoxical Cerebral Air embolism (PCAE) is a rare, under diagnosed cause of stroke that can be associated with manipulation of central venous catheters (CVC). CASE PRESENTATION: A 37 year-old woman with a history of Systemic Lupus Erythematosus (SLE), seizures and end stage renal disease presented after a hypotensive seizure episode, following a dialysis session via a CVC. She was alert with left sided hemiplegia and left sided homonymous hemianopsia in emergency department. Her National Institutes of Health Stroke Scale score was 14. Initial head CT revealed diffuse hypodensities along the right frontal, parietal, and occipital lobes sulci, suggestive of fat or air embolus versus artifact. A repeat head CT scan 4 hours later revealed no abnormalities, so initial findings considered artifactual. CT angiogram and brain MRI showed no abnormalities. Patient then admitted for seizures with Todd’s paralysis. Her mental status progressively declined with persistent neurological deficits and patient was transferred to the MICU. Repeat MRI showed extensive right hemispheric cortical and subcortical abnormality with diffusion restriction. SLE cerebritis was considered, and serological tests obtained. No lab markers were consistent with SLE cerebritis. A lumbar puncture was performed, but cerebral fluid analysis was unrevealing for an infectious process. Extensive reviews with neuroradiology suggested the presence of a cerebral air embolism as a potential complication of her dialysis catheter. A contrast enhanced transthoracic echocardiogram confirmed the presence of a patent foramen ovale as a potential nidus for our theory. As a result, she was transferred for therapy with hyperbaric oxygen.
CONCLUSIONS: A high degree of suspicion in patients presenting with neurological abnormalities after HD for PCAE is required as early treatment is essential to reducing morbidity and mortality of this complication. Reference #1: Murphy B, Harford F, Cramer F. Cerebral air embolism resulting from invasive medical procedures. Treatment with hyperbaric oxygen. AnnSurg.1985;201:242-5 DISCLOSURE: The following authors have nothing to disclose: Frances Puello, Janine Harewood, Sheelan Karim, Olumayowa Abe, Samarth Beri No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.383
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
chestjournal.org
357A
CRITICAL CARE
DISCUSSION: PCAE is a potentially catastrophic event. The diagnosis should be entertained when a sudden neurological deterioration along with hemodynamic instability occurs in the setting of manipulation of a CVC. In this case, the diagnosis was delayed due to apparent resolution of the initial CT scan findings. It has been reported that CT findings of CAE can become negative 2.5 hours after the event occurred, thus a high index of suspicion should be maintained despite negative imaging. Currently hyperbaric oxygen is the treatment of choice. Studies have shown that initiation of hyperbaric oxygen within 8 hours of onset is associated with improved neurological outcomes. In a study of 16 subjects treated with hyperbaric oxygen, 8 patients recovered completely, while 5 patients saw partial improvement. The remaining 3 participants saw no improvement. No other treatment has demonstrated mortality benefit.