Air embolism in the skull and spine as a result of a pulmonary space-occupying lesion biopsy via percutaneous puncture: a case report

Abstract

To describe a rare instance of cerebral and spinal cord air embolism that occurred after a left lower lung mass was percutaneously biopsyed under computed tomography guidance, highlighting the significance of early detection and interdisciplinary care. Following a percutaneous biopsy of a left lower lobe of the lung with a space-occupying lesion, a 66-year-old male patient had lower extremities paralysis and chest tightness. Multidisciplinary consultation and imaging verified that the lesion was a cranial and spinal air embolism. Following his recovery with hyperbaric oxygen, physiotherapy, and lumbar big pool draining and decompression, he was released from the hospital.

Introduction

With serious side effects like haemorrhage and pneumothorax, the safety of percutaneous lung aspiration biopsy as the gold standard for the pathologic identification of lung-occupying lesions has been extensively established [1]. But only 0.02–0.07% of instances result in systemic air embolism (SAE) [2], a rare but deadly consequence that even less frequently involves the central nervous system. The majority of SAE cases that have been documented in the literature thus far have only included cerebral emboli [3]. There has only been one case reported. The primary symptom was spinal cord ischaemia infarction-induced neurological impairment [4].On the other hand, no reports of air embolism involving the spinal cord at the same time have been made.

The mechanism of air embolism and pulmonary vein damage during puncture procedures are closely related. The gas enters the pulmonary venous system through ruptured blood vessels when the patient coughs or inhales deeply, and then goes through the left cardiac circulation to embolise the brain, spinal cord, or coronary arteries [5]. Notably, because of their high respiratory motility and vascular anatomic heterogeneity, lung lesions next to the diaphragm may further raise the risk of surgery. The technical requirements for punctures and postoperative monitoring techniques for such high-risk lesions, however, are not universally agreed upon in the current guidelines.

The 66-year-old male patient described in this study experienced cranial and spinal air embolism following a percutaneous lung puncture biopsy for proximal diaphragmatic surface occupancy in the left lower lung. One hour following the procedure, the patient experienced neurologic impairments. After receiving combination multidisciplinary care and a diagnosis verified by multimodal imaging, the patient recovered completely. This case aims to (1) highlight the possible hazards of puncturing a peridiaphragmatic lesion, (2) suggest early warning signs and rescue routes for SAE, and (3) offer an evidence-based foundation for improving lung puncture operation standards.

Case report

A pulmonary CT scan revealed a 1.4×0.9 cm occupying lesion in the dorsal segment of the lower lobe of the left lung, partially in the form of ground glass, in a 66-year-old male who had arrived at the Department of Oncology on November 10, 2024, with a history of coughing. He denied having a history of trauma or surgery, a history of food and drug allergies, and any overtly positive physical examination findings. He was in good health. The coagulation function, liver and renal function, and blood routine testing showed no discernible abnormalities. With the patient’s and family’s permission, a puncture biopsy of the lesion under CT localisation was carried out on November 11 in order to determine the nature of the patient’s left lung lesion. A 17G coaxial trocar was used to puncture the lesion area, four strips of diseased tissues were removed by multi-point and multi-site puncture using an 18G biopsy gun, the patient’s vital signs were stable, cardiac monitoring was administered, body membrane fixation was carried out, CT was performed to clarify the lesion, the CT localisation point was the puncture point, routine disinfection, towelling, and 2% lidocaine anaesthesia was applied layer by layer. The sampling was satisfactory. The biopsy specimens were transferred to the Department of Pathology for additional analysis once the biopsy gun and coaxial needle were removed. Repeat CT showed a little bleeding in the puncture area and a little pneumothorax on the left side. The operation of the puncture path is shown in Fig. 1. Postoperative monitoring of vital signs. At the end of the puncture biopsy, the patient felt obvious headache, had lower limb weakness, had chest tightness and chest pain, and was given oxygen treatment.

Fig. 1.

Operative puncture path diagram

The patient’s headache, chest tightness, limb numbness, and decreased limb muscle strength occurred an hour after the puncture. The examination revealed that the patient’s T36.2 °C, P59 beats per minute, R15 beats per minute, blood pressure of 137/80 mmHg, the strength of both upper limbs was grade 4, the strength of the left lower limb was grade 1, the strength of the right lower limb was grade 3, and the sensation of the thoracic 4 vertebral body below the plane vanished. An improved CT examination of the chest revealed pneumoperitoneum in the left atrium and aorta, but a complete cranial and cervical MRI revealed no evident abnormalities shown in Fig. 2. Neurology, neurosurgery, respiratory medicine, cardiothoracic surgery, spinal surgery, intensive care unit, and oncology were all consulted right away. During the consultation, the diagnosis of an ischaemic lesion of the spinal cord caused by an air embolism was taken into consideration. The patient was placed in a left lateral position, and it was advised that lumbar large pool drainage and decompression surgery be performed immediately. The patient and his family agreed to this procedure, and he was also given mannitol to reduce pressure and dehydrate, methylprednisolone sodium succinate to reduce oedema, vitamin B1, vitamin B12 nutritional nerves, hyperbaric oxygen, and other supportive treatments for his symptoms.

Fig. 2.

Left atrium and intra-aortic pneumoperitoneum seen on chest-enhanced CT

After a day, the infection decreased below the plane of the thoracic six vertebrae, and the patient’s muscle strength increased to grade 5 in both upper extremities, grade 1 in the left lower extremity, and grade 4 in the right lower extremity.

Three days later, a review cranial MRI revealed several infarcts in the cerebellum, medulla oblongata, bilateral frontal lobes, left parietal lobe, and right temporal lobe Fig. 3). Ischaemic alterations in the thoracic medulla of T5-6 segments were indicated by lumbar and thoracic MRI (Fig. 4A). At the same time, rehabilitation therapy was started.

Fig. 3.

Cranial MRI suggesting bilateral frontal and left parietal lobe, right temporal lobe, cerebellar and medullary infarcts

Fig. 4.

A MRI of the thoracic and lumbar spine suggests ischemic changes in the thoracic medulla at the T5-6 segment. B The spinal cord ischemia was better than before when reviewed 1 month later

After a month, the infection beneath the plane of the thoracic 9 vertebrae was decompensated, and the patient’s muscle strength was grade 5 in both upper limbs, grade 2 in the left lower limb, and grade 4 in the right lower limb. According to a review of the thoracic spine MRI, the ischaemic alterations in the T5–6 segments’ thoracic medulla were better than they had been previously (Fig. 4B).

After three months, the patient was released with minor dependency on daily living, reduced infection below the plane of the thoracic 9 vertebrae, grade 5 muscle strength in both upper extremities, grade 4 and grade 5 in the left lower extremity, and grade 5 in the right lower extremity.

Discussion

Pneumothorax and haemorrhage are the most frequent complications of percutaneous lung puncture biopsy, an important diagnostic procedure for lung space-occupying lesions. Systemic air embolism, particularly involving the cranium, brain, and spinal cord, is extremely uncommon, despite air embolism being a rare complication. Following a puncture biopsy of the left lower lung occupation, a 66-year-old male patient had a unique instance of systemic air embolism involving the central nervous system. The diagnostic and treatment procedures involved in this case offer significant warning implications for the clinic.

This case is unique because it involves the anterior spinal artery and the vertebrobasilar system at the same time, a double embolisation occurrence that has hardly ever been documented before. The following mechanisms could be connected to this twofold embolisation: (1) aberrant traffic between the pulmonary vein and the puncture needle tract: the patient’s CT scan revealed that the lesion was close to the hilar region, and the development of a fistula between the pulmonary and bronchial veins may offer an anatomical explanation for how air enters the body’s circulation [6]; (2) Because the patient was supine during the procedure and the puncture site was below the level of the heart, the gas was able to enter the blood vessels more easily due to the negative pressure gradient in the chest cavity [7]; (3) the patient’s violent coughing during the procedure caused violent fluctuations in the intra-thoracic pressure, which created a suction effect that allowed more gas to be inhaled into the blood vessels through the pulmonary veins.

A three-phase intervention strategy has allowed us to achieve a favourable prognosis in terms of clinical management: (1) immediate left lateral recumbency during the acute phase to limit further gas entry into the circulation [8]; and (2) by raising the blood oxygen partial pressure and producing a large diffusion gradient, hyperbaric oxygen therapy, when started within 4 h of onset, encourages the entrance of nitrogen into the blood while reducing the area of air embolism [9, 10]. Numerous research have shown that hyperbaric oxygen therapy is effective; (3) early and quick decompression through lumbar large pool drainage lowers subarachnoid space pressure following spinal artery ischaemia and enhances spinal microcirculation [11]; (4) prudent use of glucocorticoids may have lessened the oedema of spinal blood vessel endothelial cells, but more evidence-based data regarding its use in central air embolism is still required.

Among the clinical insights from this case are (1) the need to carefully assess preoperative enhanced CT for abnormal vascular traffic in lesions adjacent to the hilar region; (2) the recommendation to continuously monitor end-expiratory carbon dioxide during the operation, as its abrupt drop may serve as an early warning of an air embolism [12]; and (3) the use of the coaxial puncture technique and standardisation of the sealing operation procedure has been demonstrated to lower the risk of air embolism complications [13]. It is important to note that our patient’s immediate postoperative CT showed less pneumothorax, which should raise concerns about the potential for an air embolism.

This study bears the constraint of single-center case reporting, and future combined multicenter investigations are required to build a more effective risk assessment system. As image-guidance technology advances, the use of cone-beam CT real-time navigation or electromagnetic tracking systems is projected to lessen the possibility of such catastrophic difficulties on a technological level [14].

Authors’ contributions

Yong Bai and Xiaoya Zhang contributed equally to this work as co-first authors. Yanrong Sun and Lehong Zhou jointly supervised the study as co-corresponding authors. The individual contributions are detailed as follows: Yong Bai: Conceptualization, patient management, data collection, manuscript drafting, critical revision of intellectual content. Xiaoya Zhang: Literature review, imaging analysis and interpretation, figure preparation, manuscript editing. Yanrong Sun: Clinical supervision, study design, diagnostic validation, manuscript revision, final approval. Lehong Zhou: Pathological analysis, study coordination, funding acquisition, administrative support, final approval. † These authors share first authorship. * These authors share corresponding authorship. Corresponding author’s e-mail address: 240867853@qq.com.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Ethics approval was not required for this case report. Written informed consent for publication of this case and accompanying images was obtained from the patient.

Consent for publication

Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient. A copy of the consent form is available for review by the Editor of this journal.

Competing interests

The authors declare no competing interests.