Clin Endosc.  2014 May;47(3):275-280. 10.5946/ce.2014.47.3.275.

Fatal Cerebral Air Embolism Due to a Patent Foramen Ovale during Endoscopic Retrograde Cholangiopancreatography

• Bastovansky A
• Stollberger C
• Finsterer

• KMID: 2049027
• DOI: http://doi.org/10.5946/ce.2014.47.3.275

Abstract

Fatal air embolism to the cerebrum during an endoscopic retrograde cholangiopancreatography (ERCP) has not been reported in a patient with a biliodigestive anastomosis and multiresistant extended-spectrum beta-lactamase Escherichia coli (ESBL) bacteremia. A 59-year-old woman with a history of laparoscopic cholecystectomy and iatrogenic injury of the right choledochal duct, choledochojejunostomy (biliodigestive anastomosis), recurrent cholangitis, revision of the biliodigestive anastomosis, recurrent liver abscesses, and recurrent stenting of stenotic bile ducts, was admitted because of fever and tenderness of the right upper quadrant. On ERCP, a previously deployed covered Wallstent was replaced. Blood cultures grew ESBL. After stent removal 8 days later, the patient did not wake up and developed arterial hypotension and respiratory insufficiency, requiring mechanical ventilation. Computed tomography scans showed extensive air embolism to the liver, heart, and cerebrum. She died 1 day later. Although the exact pathogenesis of the fatal cerebral air embolism remains speculative, the nonphysiological anatomy and chronic infection with ESBL may have been contributory factors.

Keyword

Brain edema; Intracranial pressure; Embolism, air; Endoscopy; Complication

MeSH Terms

Bacteremia
beta-Lactamases
Bile Ducts
Brain Edema
Cerebrum
Cholangiopancreatography, Endoscopic Retrograde*
Cholangitis
Cholecystectomy, Laparoscopic
Choledochostomy
Embolism, Air*
Endoscopy
Escherichia coli
Female
Fever
Foramen Ovale, Patent*
Heart
Humans
Hypotension
Intracranial Pressure
Liver
Liver Abscess
Middle Aged
Respiration, Artificial
Respiratory Insufficiency
Stents
beta-Lactamases

Figure

• 

  Fig. 1 Computed tomography scan of the thorax and the abdomen showing air (arrows) within (A) the aorta, (B) pericardium, (C) bile ducts and right atrium, and (D) inferior caval vein.

• 

  Fig. 2 (B, D) Cerebral magnetic resonance imaging 2 hours after endoscopic retrograde cholangiopancreatography shows multiple hypointense lesions in the subcortical and periventricular white matter. (A, C) The lesions were also hypodense on cerebral computed tomography.

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