Cerebral Arterial Gas Embolism Patients Treated with Hyperbaric Oxygen at Hennepin County
Medical Center Hyperbaric Oxygen Chamber from 1987-2010: Data table
#
1
2
Age
57
73
Sex
M
M
A/V
V
A
Cause of
embolism
Right CVC catheter
removal
Pneumothorax
related to lung biopsy
3 days prior to CAGE,
colonoscopy done 1
day prior to CAGE (air entry could be
due to either of two
events)
Colonoscopy 1 day
back, lung biopsy with
Pneumothorax 3 days
back, Metastatic Rectal
CA, COPD, lung nodule
bx positive for CA ,
carotid stenosis , IDDM,
HTN, CAD, previous
CVAs, DVT, OSA, IBD
Unresponsiveness with
decerebrate posturing,
brain stem reflexes
present.
CT scan showing
air/infarct/ edema
in R MCA territory
Cardiac catheterization
2 days prior for
Congenital heart
disease
L hemiplegia with
incontinence
CT head showing
air in R MCA
distribution, MRI
with acute infarct
in R MCA territory
Multiple HBO2 sessions
for treatment of soft
tissue radiation injury to
mandible, emphysema.
R sided hemiplegia upon
ascent during 28th
treatment
DM2, pain meds abuse,
hypothyroidism,
hyperlipidemia
Severe right sided
headache,photophobia,
blurring vision
60
M
A
5
50
F
V
Self-exploration of
porta-cath
6
7
55
56
F
M
M
V
Diagnostic
imaging
before HBO2
Tachypnea, SOB, stool
incontinence, right gaze
preference, L sided
paralysis, and complete
L sided neglect.
4
3
Initial Sign and
Symptoms of CAGE
R side 15% TBSA
burn,history of alcohol
abuse, pancreatic CA
s/p resection
&esophagectomy,
depression
Cardiac
catheterization
Pulmonary
overpressure
accident with CAGE
during HBO2
treatment for soft
tissue radiation
injury
3
Medical
comorbidities
V
30-55 cc of air
introduced during
dialysis for ESRD
CAD s/p CABG s/p PCI,
HTN, DM2,
polysubstance abuse
including EtOH
A
Percutaneous
closure of ASD
ASD, NIDDM, OSA,
HTN
LOC during dialysis for
ESRD,Chest
pain,dyspnea, nausea,
headache, R sided focal
weakness with
paresthesia in R leg
LUE paralysis and L
facial droop and LLE
weakness and
confusion, altered mental
status
CT head showing
air in R MCA
territory
Not done
CT head showed
air in L jugular
vein, cavernous
sinus, sup
ophthalmic veins
and
cervicomedullary
junction
Time to
HBO2
Other diagnostic
tests& treatments
3 hrs
Myringotomy BL,
intubation, IV rt-PA
loading dose.
Unremarkable EKG
changes, negative
troponins, CXR: no
pneumothorax, LLL
opacity consistent with
atelectasis and small
pleural effusion
13hrs 20
mins
Intubation, chest tube
for recent
pneumothorax,
elevated troponins,
EKG showing anterior
wall MI.
13 hrs 53
mins
ECHO showing air in
R ventricle shunting to
left & thrombus in IVC,
CXR with left hilar
infiltrate, Myringotomy
BL, intubation
1 hrs 12
mins
None
CT head with no
air in vasculature
3 hrs
EKG: Sinus rhythm
with mild inferior ST-T
wave changes
ASA, NTG, Bedside
ECHO likely
ASD,EKG:LVH and
non-diagnostic ST
segment changes,
CXR: chronic L pleural
effusion and apparent
atelectasis, bilateral
myringotomy
CT head with air
embolus in right
frontal lobe
4hrs 48
mins
EKG:sinus tachycardia
with no ST elevations.
~ 13 hrs
HBO2
sessions
Treatment
table
3
USN Table 6
x 1 and table
5x2
1
2
USN Table 6
USN Table
6x2
Complication
during HBO2
Final Outcome
None
Improved. Completely
recovered LUE motor
function, LLE strength
3/5. f/u CT with evolving
infarct, no air
none
Died (Diffuse brain
injury). F/U head CT :
massive right MCA/ACA
infarct/edema & smaller
amount or scattered air
in R MCA distribution.
none
Died. F/U head CT
Massive right MCA
infarct, cerebral edema,
air foci.
1
USN Table 6
none
Resolution.
Follow up MRI showed
mild ischemia in L perirolandic and ant parietal
lobes
1
USN Table 6
none
Resolution of vision
blurriness but persistent
HA. F/U head CT: no air
none
Resolution of symptoms
and neurologic deficits.
F/U head CT infarct left
frontal lobe
none
Improved. Follow up CT
head showing small R
anterior frontal infarct
with no residual air.
1
1
USN Table 6
USN Table 6
Cerebral Arterial Gas Embolism Patients Treated with Hyperbaric Oxygen at Hennepin County
Medical Center Hyperbaric Oxygen Chamber from 1987-2010: Data table
8
9
10
11
53
72
53
66
M
M
M
M
A
V
V
A
Cardiac ablation
procedure for
Chronic Afib
Chronic afib, TBI w/ L
sided weakness,
seizure disorder
Confusion,
hypotension,bradycardia,
chest and back pain w/
third deg heart block
Hickman catheter
disconnected
HTN, Diabetes s/p laser
for retinopathy, COPD
and CRF
AMS, acute bilateral
blindness,subjective
weakness,
SOB,hypotension,
hypoxemia
cardiac
radioablation
CAD with coronary
artery stents, atrial fib/
flutter, SVT
Severe L facial droop,
left visual field cut with
slurred speech
Carotid and
Innominate stenting
CAD, large vessel
atherosclerotic dis,
COPD, obesity,
dyslipidemia,
12
41
F
A
Lung biopsy
spindle cell CA, R hip
and leg amputation,
13
41
F
V
CVC removal
ESRD s/p renal
transplant, HTN,
cholecysectomy
CT head with gas
embolism in the
brain.
AMS, not moving
extremities
Head CT wit BL
cerebellar and
pontine infarcts
thought to be
metastatic emboli
initially, no air
seen
> 30 hrs
Seizures, coma(GCS 45, responding to pain)
CT head: normal,
MRA: normal
3.5hrs
CT head with
diffusely low
attenuation, no air
28hrs
EKG:sinus rhythm,
poor R wave
progression, lateral ST
depression, CXR: hilar
congestion, Swanganz catheter and
three chest tubes,
myringotomy BL
CT head: normal
6.5hrs
Not done
5.25hrs
F
A
Aortic valve
replacement
CAD, CHF, severe AS,
Afib, COPD
15
40
F
V
CVC cap off
s/p ventral hernia repair
with ileus, IBS,
migraine, malnutrition
Seizures after
anesthesia wore off,
unresponsiveness
Sudden right
hemiparesis, numbness,
headache, and aphasia
when she sat up
CVC removal
Guillain-Barre syndrome
w/ neurological motor
deficits in BL LE 3/5
strength, also
decreased sensation
Sudden hypotension,
tachycardia, hypoxia,
chest pain, seizure
F
V
Unknown
but likely
less than
12 hrs
Left sided facial, arm and
leg paralysis, right gaze
preference
86
17
CT head – right
occipital infarct
CT head with air
in cerebral
vasculature (R
MCA dist)
10 hrs 10
mins
Heparin,Myringotomy
BL, EKG: long QT,
PVCs and BBB
Intra-arterial rt-PA prior
to diagnosis of CAGE,
followed by CT head
showing gas embolism
,intubation, sedation,
myringotomy, EKG:
new lateral ST
depression
Cardiac ECHO:
decreased EF,
elevated trops 7.4, CK
778, EKG: sinus tach,
anterolateral T wave
changes. CXR: left
lower lobe atelectasis.
Myringotomies
Cardiac ECHO
showing ASD w/ R-->L
shunt. Elevated trops,
lactate, CK. EKG: nonspecific ST-T changes,
CXR: normal
14
16
None
Cardiac
angiographyshowed
occluded LAD with air
in L ventricle. TTE –
LAE, mod TR,
elevated trops, ST
elevation. CXR:
bibasilar atelectasis
with no infiltrates.
CXR: air in pulmonary
artery and right
ventricle,pulmonary
edema, EKG: peaked
T-waves, left ant
fascicular block,
potassium was 6,
elevated troponins
Likely ~
12 hrs
4-6 hrs
CXR:
normal,myringotomy,
EKG: normal
CXR vascular
congestion, ABG –
hypoxia, EKG w/ sinus
tachy. Cardiac ECHO
showed no air, EKG w/
sinus tachy
1
USN Table 6
none
Resolution
Unchanged. F/u MRI
right occipital infarct.
EEG: R posterior
quadrant
epileptogenicity.
DNR/DNI >hospice care
1
USN Table 6
aborted d/t
seizures and
respiratory
distress
1
USN Table 6
with ext at 60ft
and 30ft
none
Improved. Follow up CT
with infarct in R MCA
territory.
1
USN Table 6,
aborted due to
Cushing's
reflex.
Brady-asystolic
event, declining
neurological
status
Died. F/U head CT with
massive R basal ganglia
ICH with edema &
midline shift, loss of
brain stem reflexes >
Comfort care.
1
USN Table
Table 6
none
Unchanged. Bilat
cerebellar and pons
infarcts on f/u MRI
1
USN Table 6
– aborted due
to seizures
Continued
seizures during
HBO2
Improved.
2
Table 6, Table
5
Continued to
seize sometimes
during HBO2
Unchanged
1
USN Table 6
None
Improved
1
USN Table 6A
Bilat pleural
effusion, SOB
Improved
Two seizure
episodes during
HBO2 treatment
with headache
Cerebral Arterial Gas Embolism Patients Treated with Hyperbaric Oxygen at Hennepin County
Medical Center Hyperbaric Oxygen Chamber from 1987-2010: Data table
17
18
70
49
F
F
V
V
Abdominal
insufflation after
resection of lung
cancer
CV catheter leak
Lung cancer, COPD,
HTN, PFO
ESRD, IDDM, CABG,
Gastroparesis CVA,
CHF with pulm edema
hypothyroid, migraine
HA
19
38
F
V
R Internal jugular
catheter
accidentally came
out in clinic
20
42
M
V
Subclavian CVC
line removed
HIV, pancreatitis with
sepsis
ESRD on dialysis,
AIDS, HTN
s/p tongue CA resection
radical neck dissection,
pulm mets, partial
pneumonectomy
Arthritis, Lupus, central
line for chemotherapy
21
42
M
V
22
56
M
V
End of dialysis
quinton fell off,
when rolled over in
bed catheter noted
bleeding.
HBO2 Rx for
osteoradionecrosis
16th treatment
during ascent
V
L Subclavian CVC
line removal.
Patient coughed
during removal
Ulcerative Colitis,
Migraine HA
V
Patient heard air
rush into neck when
SwanGanz
removed, cordis left
in place
GI Bleed, aortojejunal
fistula, AAA, CABG
V
Dialysis tubing
disconnected while
on dialysis. Venous
line of Quinton
ESRD on dialysis. Afib
DM, Hyperkalemia,
Dementia, Breast CA
23
24
25
17
73
80
M
M
F
Acute hypotension (SBP
70 mmHg), coma
Day 1: CP, trop 1.1. Day
3: CP, nausea, SOB, R
neck and jaw pain, R
parietal HA . Day 4 R
neck and jaw pain
,confusion, anxiety
HA, stiff LUE, new
cardiac rub. Day 5
sudden deterioration,
worse CP SOB
irritability, somnolent,
LUE weakness
Abrupt Loss of
Consciousness,
decrease mental status,
dizziness. Progressing
ARDS, disorientation
fluctuating mental status
Cardiopulmonary arrest
s/p CPR sedated and
paralyzed. Seizures after
resuscitation, GCS 3
Heard woosh of air, felt
dizzy R sided heaviness,
decreased R arm
movement, R leg heavy
&weak, R lower facial
weakness &"numbness"
speech disturbance.
Weakness R arm and
leg without neglect
Sudden SOB, near
syncope during CXR,
questionable seizure
activity, obtundation,
decreased vision
Reduced level of
consciousness ,
obtunded, posturing
Respiratory then cardiac
arrest,resuscitated to
afibwith rapid vent
response, eyes open,
unresponsive, no
CT head: 2 hrs
after event
showing small
foci of air in post
parasagittal left
frontal lobe
7 hrs
CT head: air,
multiple small
infarcts.
HCT 2 days prior:
normal.
MRI 2 days prior:
multiple bilateral
infarcts.
CXR: air under
diaphragm,
subcutaneous
emphysema. Normal
trops, CK 836, EKG:
inverted T waves. Two
chest tubes,
Myringotomy BL.
1
USN Table 6
none
Died. Withdrawal of care
on day 2. MRI day after
admission: bihemispheric infarcts.
CT head: normal
28 hrs
CT head: normal
10.75 hrs
TTE: air in RV, no
shunt, dec LV Fxn, inf
LVWMA. EKG: Q
wave inferiror
leads,,LVH. CXR:mild
cardiac, pulm edema.
TEE - no air, no shunt
poss AV malform
Myringotomy BL,
LP normal, CXR - BL
infiltrates, Echo:
normal, no air.Chest
CT – diffuse BL
infiltrateswith pulm
edema. EKG: sinus
tachy. Intubated.
Chest CT/ Angio:
normal.EKG: sinus
tachy perihilar
infiltrates, pulm edema
Not done
6 hrs
EKG: NSR, LVH. CXR
interstitial pulm
edema, cardiomegaly.
EEG: normal
1
USN Table 6
none
Resolved
Not done
0immed
N/A
1
USN Table 6
none
Resolved
CT head: with air
in cerebral
vasculature
~ 4.45
hrs
1
USN Table 6
none
Resolved. F/U head CT
no air or infarct
CT head: no
acute infarct or air
~ 9hrs
EKG: incr voltage.
CXR: interstitial
changes
Cardiac Echo: air in BL
A+V. Loud cardiac
murmur. CXR - no
free air cordis
removed, repeat echo
- no air. EKG: sinus
tachy, LVH CXR: BL
infiltrates, pulm
edema, intubated, aline radial cutdown
1
USN Table 6
Unstable BP
~ 5 hrs
CXR: BL pleural
effusion, R interstitial
pattern pulm edema.
Intubated
1
USN Table 6
none
5 days
Not done
1
USN Table 6A
fever 103.4
Improved. Speech and
motor activity on R
arm/leg improved, Dec
spasticity on Left
1
USN Table 6
none
Resolved
1
USN Table 6
none
Unchanged. Anoxic
brain Injury, DNR/DNI to
nursing home
Resolved.
Unchanged. Family
withdrew support & pt
passed away two weeks
later due to worsening
from probable aspiration
Cerebral Arterial Gas Embolism Patients Treated with Hyperbaric Oxygen at Hennepin County
Medical Center Hyperbaric Oxygen Chamber from 1987-2010: Data table
spontaneous movement
absent pupillary and
corneal reflexes, +gag,
triple flexion.
26
27
28
29
30
31
32
33
34
67
7
81
26
48
24
34
43
50
F
F
M
F
F
F
F
F
F
V
A
CT guided
transthoracic
needle biopsy of
pulm mass
Repair ASD,
cardiac bypass,
ventilator
malfunction allowed
air into arterial
system via ASD
pneumonia and
septicemia. F/U imaging
diffuse edema/ bilateral
infarct.
Pulmonary mass
Confusion becoming
more obtunded, R
decorticate posturing, R
Babinski, L gaze
preference, dysarthria
MRI brain:
negative for bleed
or air
22 hrs
Cardiomegaly from ASD
Not awakening from
anesthesia, GCS 3
CT head:
attenuation on the
R parietal area,
no air.
3.25 hrs
EEG diffuse delta
activity in L, EKG:
NSR, CXR: focal LLL
edema vs. atelectasis
V
CT guided biopsy of
pulmonary mass
Prostate CA, Colon CA,
Pulm Fibrosis, CAD, AS
porcine aortic valve
replacement
A
Catheter placement
in R femoral artery
for L carotid
injection
Recalcitrant epilepsy
Became deeply
unresponsive during
procedure, GCS 3,
Seizure
First inappropriate
giggling,R hemiparesis
(facial and RUE),
aphasia, R sided
neglect, seizures for 90
seconds.
Mitral Valve Plasty
CRF. Mitral Stenosis,
Aortic valve
Insufficiency
Arrested, bypass, aortic
balloon pump, GCS 3,
Ventricular tachy x 2 in
ED.
Not done
~ 8 hrs
EKG: NSR
Cardiac Echo: Large
air in L CVC, air in R
ventricle shunting to L
through septal defect.
Chest
tube.Myringotomy
WADA Study Intractable
Seizure Disorder
Depressed mental
status, dysarthria, R
sided weakness > 20
min.
CT head: no
abnormality, no
air
6.25 hrs
Myringotomies
V
A
Left internal carotid
Injection
A
L common carotid
angiogram,10cc air
injected
Neck laceration zone,
needing carotid
angiogram
Decreased mental
status, not responding to
voice or sternal rub,
pupils reactive,
withdraws to pain all
extremities,RUE toes up
V
Open heart surgery
for removal of
infected right atrial
thrombus. Air
introduced into R
ventricle, found in
LV. Surgery proven
PFO
Sepsis due to positive
blood cult Staph
epidemidis from long
term indwelling Hickman
catheter
Did not recover normal
mental statusafter
surgery. Obtunded, not
following commands.
Pupils reactive, DTR
intact, Clonus lower
extremities,
MV replacement 1981,
TIA's
Decerebrate- decorticate
posturing, pupils
fixed/dilated, deep coma,
improving over 24 hrsto
spont moving all extr and
opening eyes. Hyperreflexic, sustained
clonus, BL Babinski.
A
Mitral Valve
Replacement air
introduced
canalizing aorta
CT head: air in
cerebral
circulation
~4.5 hrs
Not done
5.5 hrs
Not done
Not done
CT head: no
abnormality
EKG: NSR, CXR:
small
rightpneumothorax.
R chest tube
1
USN Table 6
none
Improved
1
USN Table 6a
none
Improved
1
USN Table 6a
Status epilepticus
during HBO2 (no
response to
dilantin &
phenobarbital)
Improved. Family
withdrew care later on
and died. F/u CT diffuse
cerebral edema, loss of
sulci.
1
USN Table 6
None
Resolved
1
USN Table 6a
balloon pump
stopped at 60'
patient tolerated,
no consequences
Unchanged. Withdrawal
of support and passed
away
1
USN Table 6a
Improved. MRI L middle
temp lobe abnormality
(old), No infact/edema
1.5 hrs
EKG: diff ST-T
depression, sinus
tachy, no infiltrates
1
USN Table 6a
Sinus squeeze
Status epilepticus
during HBO2 for
about 2hrs.
Seizures due to
illness did not
stop with air
break
~ 6 hrs
Air aspirated at time of
surgery from both
ventricles. EKG: NSR,
ST elevation inferior
and lateral. BL chest
tubes. CXR: no
infiltrates or effusion.
1
USN Table 6a
None
Improved. Aphasic, slow
speech, R hemiparesis,
ambulates
independently, lives at
home with health aide
Improved. At d/c
answering questions
sometimes
inappropriate, follows
commands, not
speaking spont, LEs >
UEs spont extremity
movement. F/U head
CT: no acute changes
30 hrs
CXR: no infiltrate,
cardiac ECHO: NSR,
EEG improving
response,deep coma.
Intubated, BL chest
tubes placed, CVC line
USN Table
6A extended
by USN Table
4
Post
HBO2consolidatio
n in LLL,
progressed and
prevented further
HBO2 (O2toxicity)
Improved. F/U CT with
cerebral edema
consistent with past air
embolism.
1
Cerebral Arterial Gas Embolism Patients Treated with Hyperbaric Oxygen at Hennepin County
Medical Center Hyperbaric Oxygen Chamber from 1987-2010: Data table
Intubated, ventilator L
CV line, R removed
Acute SOB, dyspnea,
CT head: ICH
increase pulm edema
35
49
M
V
tachycardia, confusion
improving, no air
~ 4.5 hrs
NSR
1
6a
None
Improved
Chest pain, SOB,
headache when stood
up.Noted wetness and
L side decreased
bubbling from Hickman
pin prick and light
Hickman catheter
Idiopathic
site, split in it, was
EKG: diffuse T wave
touch and mild
Resolved. F/U head CT
36
25
F
V
split
dysautonomia, TPN
playing with dog.
CT head : normal
~ 5.5 hrs
inversions
1
USN Table 6a
motor weakness
no change.
Abbreviations used: #= number, CAGE = cerebral arterial gas embolism, A/V= arterial/venous, CVC= central venous catheter, HBO2 = hyperbaric oxygen, F/U =follow up, TBSA=total body surface area, s/p=status post, rt-PA= recombinant tissue plasminogen
activator, CXR: chest x-ray, LLL= left lower lobe, CAGE= cerebral arterial gas embolism, CA= cancer, MCA=middle cerebral artery, BL=bilateral, CAD= coronary artery disease, CABG= coronary artery bypass graft, PCI=percutaneous coronary intervention, EtOH= alcohol,
LOC=loss of consciousness, ESRD= end stage renal disease, Afib= atrial fibrillation, TBI=traumatic brain injury, AMS=altered mental status, ICH=intracerebral hemorrhage, CRF= chronic renal failure, ASD= atrial septal defect, USN= United States Navy.
Patient cut
subclavian CVC
ICH, left hosp. AMA w/
CVP line