Acute Respiratory Distress Syndrome after Onyx Embolization of Arteriovenous Malformation

Isaac Tawil,Christopher L Taylor,Andrew P Carlson

doi:10.1155/2011/918185

Abstract

Purpose. We report a case of a 60-year-old male who underwent sequential Onyx embolizations of a cerebral arteriovenous malformation (AVM) which we implicate as the most likely etiology of subsequent acute respiratory distress syndrome (ARDS). Methods. Case report and literature review. Results. Shortly after the second Onyx embolization procedure, the patient declined from respiratory failure secondary to pulmonary edema. Clinical entities typically responsible for pulmonary edema including cardiac failure, renal failure, iatrogenic volume overload, negative-pressure pulmonary edema, and infectious etiologies were evaluated and excluded. The patient required mechanical ventilatory support for several days, delaying operative resection. The patient met clinical and radiographic criteria for ARDS. After excluding other etiologies of ARDS, we postulate that ARDS developed as a result of Onyx administration. The Onyx copolymer is dissolved in dimethyl sulfoxide (DMSO), a solvent excreted through the lungs and has been implicated in transient pulmonary side effects. Additionally, a direct toxic effect of the Onyx copolymer is postulated. Conclusion. Onyx embolization and DMSO toxicity are implicated as the etiology of ARDS given the lack of other inciting factors and the close temporal relationship. A strong physiologic rationale provides further support. Clinicians should consider this uncommon but important complication.

Highlights

We report a case of a 60-year-old male who underwent sequential Onyx embolizations of a cerebral arteriovenous malformation (AVM) which we implicate as the most likely etiology of subsequent acute respiratory distress syndrome (ARDS)
The Onyx copolymer is dissolved in dimethyl sulfoxide (DMSO), a solvent excreted through the lungs and has been implicated in transient pulmonary side effects
Onyx embolization and DMSO toxicity are implicated as the etiology of ARDS given the lack of other inciting factors and the close temporal relationship

Summary

History and Presentation

This 60-year-old male initially presented with a history of seizures and progressive left-sided hemiparesis. A 3 cm AVM was discovered in the right posterior frontal lobe, just anterior to the central sulcus (Figure 1). The patient’s pastmedical history included hypertension, diet-controlled diabetes mellitus, and mild chronic obstructive pulmonary disease. Medications included levetiracetam for seizure control and metoprolol for hypertension. It was decided to perform an operative resection of the AVM after sequential Onyx embolization procedures

Interventions and Hospital Course

Findings

Discussion

Conclusion