Timothy Zinkus, MD
Pediatric Neuroradiology Section Chief
Children's Mercy Hospital Kansas City, United States
Disclosure information not submitted.
Stephen Pfeiffer, MD (he/him/his)
Children's Mercy Hospital Kansas City
Kansas City, MO
Disclosure information not submitted.
Jessica Wallisch, MD
Pediatric Critical Care Medicine Faculty; Assistant Professor
Children's Mercy Hospital Kansas City, United States
Disclosure information not submitted.
Title: A Pediatric Case of Massive Cerebral Air Embolism from Pulmonary Metastases
Background: Cerebral air embolism is a rare but catastrophic event. Most reported cases are iatrogenic in adult patients although scant reports exist in association with pulmonary arteriovenous malformations and trauma. We present a pediatric case due to fistulous metastases.
Description: A 17-year-old previously healthy male presented with new onset seizures in status epilepticus after one month of abdominal pain, nausea and vomiting. He was intubated for airway protection at the referral facility where initial non-contrast CT head showed intracranial air conforming to the subarachnoid spaces of the supratentorial brain. CT chest with contrast revealed a left upper lobe metastasis with dilated vessels and air within the nodule suggesting a fistulous connection. CT abdomen demonstrated multiple retroperitoneal masses and a right testicular tumor morphologically consistent with a germ cell tumor. The patient was transferred to our quaternary center for critical care management. MRI brain on admission showed diffuse cortical diffusion restriction consistent with ischemia with resolution of intracranial air. He received neuroprotective care but was not a candidate for hyperbaric oxygen therapy due to clinical instability and timecourse from onset of embolism to transfer. He remained obtunded without further seizure but developed a non-sustained wide complex ventricular tachyarrhythmia and anisocoria. Repeat CT head demonstrated an evolution of symmetric ischemia and cerebral edema with impending herniation. As his neurologic failure progressed, myoclonus with weak brainstem reflexes were persistent. The patient’s hospital course was further complicated by acute respiratory distress syndrome and septic shock secondary to bacteremia after initiating chemotherapy. Parents withdrew mechanical support due to severe irreversible neurologic insult in the setting of oncologic diagnosis and multisystem organ dysfunction.
Discussion: We hypothesize that recurrent emesis led to increased intrathoracic pressure, allowing air embolization via necrotic pulmonary metastasis into his arterial circulation via a fistulous connection. This led to a catastrophic spontaneous cerebral air embolism presenting as status epilepticus. More data is needed on efficacy of delayed initiation of hyperbaric oxygenation for treatment of air embolism.