Abstract
A 79-year-old gentleman developed a severe right hemispheric syndrome (NIH Stroke Scale [NIHSS] 20) within minutes of undergoing left atrial appendage occlusion (LAAO). Stroke protocol imaging showed air emboli in the right hemispheric subarachnoid space with no large vessel occlusion on non-contrast CT scan.
He had significant past medical history including atrial fibrillation on apixaban 2.5 mg BD, Ischaemic cardiomyopathy with implantable cardiac defibrillator (ICD) in situ, chronic renal failure, and abdominal aortic aneurysm with endoluminal graft repair in 2009.
He was promptly managed by high flow oxygen, Trendelenburg position for 10 minutes followed by abbreviated hyperbaric oxygen (HBO) therapy over two days as our patient was not able to tolerate full duration of therapy. There was rapid improvement with no significant clinical or radiologic sequelae. An inpatient MRI Brain was not possible due to incompatible ICD leads and was completed day 40 from the event.
Conclusion Air embolism is a rare complication of LAAO which can lead to cerebral ischemia and has the potential to cause severe neurologic deficits.1 Although it is possible that the patient’s recovery was spontaneous, it is also likely that there was a beneficial effect of prompt treatment with high-flow oxygen and HBO therapy in reducing the size of gas bubbles.2 There are no formal trials for use of HBO therapy in cerebral air embolism, although, its use is justified based on clinical experience and properties of gas exchange.
References
Muth CM, Shank ES. Gas embolism. N Engl J Med. 2000;342(7):476–82
Beevor H, Frawley G. Iatrogenic cerebral gas embolism: analysis of the presentation, management and outcomes of patients referred to the Alfred Hospital Hyperbaric Unit. Diving Hyperbaric Medicine 2016;46:15–21.
