Acute and Subacute Neurovascular Impact of Cryptogenic Air Emboli (P12-5.020)

Abstract

<h3>Objective:</h3> To describe a unique case of severe, delayed ischemia secondary to air embolism. <h3>Background:</h3> Accidental air embolism is a rare cause of ischemic stroke that is becoming increasingly well-described in the literature. However, the mechanism and severity of this type of injury can vary, with significant ischemia typically emerging early in the course of care. To our knowledge, delayed ischemia in this setting has rarely been described. <h3>Design/Methods:</h3> We describe a hospitalized patient who developed cryptogenic air emboli resulting in acute neurologic changes that appeared to improve with emergent care. However, follow up imaging revealed delayed ischemia not identified on initial radiography. <h3>Results:</h3> A stroke code was called for an unresponsive, hospitalized 75-year-old man. On evaluation, he was found to be obtunded with forced left gaze deviation concerning for possible non-convulsive status epilepticus (NCSE). He was treated acutely for seizure and subsequent stat CT head revealed air within the right greater than left hemispheric cortical veins with loss of sulcation, concerning for developing ischemia. On review of his hospitalization, prior TTE showed no PFO. Retrograde movement of air into the cortical veins was the hypothesized etiology,¹ but the source of the air in this case remains cryptogenic. MRI obtained 5.75 hours after the patient’s last known well showed subtle diffusion restriction without definitive cortical infarction and follow up CT head approximately 13 hours afterward showed near complete resolution of the air emboli. However, MRI 4 days later demonstrated diffusion restriction and cerebral edema throughout multiple vascular territories, consistent with venous infarction. <h3>Conclusions:</h3> This case highlights that venous air emboli can cause delayed ischemia that may not be appreciated on initial dedicated brain imaging. As such, affected patients may require intensive neurocritical care irrespective of initial radiographic findings. <b>Disclosure:</b> Dr. Gummerson has nothing to disclose. Dr. Parasram has nothing to disclose. Dr. Peng has nothing to disclose. Dr. Picard has nothing to disclose. Dr. Kahn has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Biohaven. Dr. Kahn has received personal compensation in the range of $50,000-$99,999 for serving as a Consultant for Chronius. Dr. Kahn has stock in Coaptech. Dr. Kahn has stock in Quantum Labs. Dr. Kahn has stock in FVC Health. Dr. Kahn has stock in TEO Science . Dr. Kahn has received intellectual property interests from a discovery or technology relating to health care. Dr. Angelus has nothing to disclose. Dr. Bhatt has nothing to disclose. Dr. De Havenon has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Integra. Dr. De Havenon has stock in Certus. The institution of Dr. De Havenon has received research support from NIH/NINDS. The institution of Dr. De Havenon has received research support from Regeneron Pharmaceuticals. The institution of Dr. De Havenon has received research support from AMAG Pharmaceuticals. The institution of Dr. De Havenon has received research support from AMGEN. Dr. De Havenon has received publishing royalties from a publication relating to health care. Dr. Jasne has nothing to disclose. Dr. Magid-Bernstein has nothing to disclose.