Objective:

A case report of air embolism causing middle cerebral stroke following lung biopsy while sitting up.

Background:

Air embolism is an uncommon but catastrophic complication of lung biopsy with high mortality and morbidity rate.

Design/Methods:

Retrospective analysis of imaging and chart review done. Verbal consent taken from patient over telephone. 

Results:

A 69 year-old male with hypopharynx squamous cell carcinoma underwent a lung needle biopsy for a right-upper lobe nodule with concern for metastasis of the cancer. During the CT guided biopsy with interventional radiology, patient was unable to tolerate laying flat, and had to sit up during the procedure. Immediately after the tissue was obtained successfully, the patient had forced right gaze deviation and left hemiplegia. Stroke-code was called, and initial assessment recorded National Institute of Health Stroke Scale (NIHSS) of 23 representing right middle cerebral artery syndrome. Subsequent CT Head showed right frontal pneumocephalus with no large vessel occlusion seen on CT Angiogram. Subsequently, patient was laid flat, with 100% high-flow oxygen. Repeat CT Head at 12 hours showed resolution of the pneumococephalus and improvement of patient’s symptoms with residual left hand weakness and NIHSS 0. MRI Brain at 24 hours showed a small area of diffusion restriction in the right motor cortex. At 30 day follow up, there was improving left hand weakness and no other focal motor deficits. 

Conclusions:

Stroke related to air embolism after a lung biopsy is a rare occurrence. Hyperbaric oxygen is the first line treatment for air embolism but it was unavailable at our center. Our patient had good outcomes with only mild residual focal motor-deficits by immediately laying flat and delivery of high-flow oxygen. Ensuring proper positioning during lung biopsy is important and can prevent such catastrophic complications. Hence, protocols should be in place to abort the procedure when proper positioning cannot to be ensured.