Cerebral air embolism with intra-pleural fibrinolytic therapy

SESSION TITLE: Procedures Case Report Posters 5 SESSION TYPE: Case Report Posters PRESENTED ON: 10/11/2023 12:00 pm - 12:45 pm INTRODUCTION: Chest tube and fibrinolytic therapy are frequently used to manage empyema and parapneumonic effusions. While typically considered low-risk procedures [1], they can potentially cause life-threatening complications like Cerebral Air Embolism (CAE), as described in the case below. CASE PRESENTATION: A 63-year-old patient was admitted with two months of cough and shortness of breath. Computed Tomography (CT) scan of the chest showed an air-fluid collection in the right pleural cavity. She was started on antibiotics and underwent tube thoracostomy with a 12-French pigtail catheter. Due to minimal output and continued symptoms, tissue Plasminogen Activator and Dornase Alpha (tPA/Dornase) therapy was started with a good response. Immediately after the third dose of tPA/Dornase, the patient developed dysarthria and left hemiparesis. Imaging revealed air embolism in bilateral frontoparietal sulci with acute cortical infarcts in the right frontal and parietal lobes. She was treated with 100% oxygen with a nonrebreather mask and had a gradual improvement across all neurological domains and was eventually discharged to a rehabilitation center for ongoing physical therapy. Her pleural effusion resolved after a week of parenteral antimicrobials, after which the chest tube was removed, and she completed a 4-week antibiotic course. DISCUSSION: CAE is an infrequent but potentially life-threatening complication of intra-pleural fibrinolytic therapy. While the exact mechanism of CAE is uncertain, it is speculated that fibrinolytics cause erosion of the fibrin layer of the visceral pleura and peripheral pulmonary veins, creating connections that allow air bubbles to enter pulmonary venous circulation [2]. While hyperbaric therapy has been used in most reported cases, oxygen therapy alone has also been effective [3]. Timely diagnosis and early initiation of treatment are critical to mitigate the morbidity and mortality associated with CAE. CONCLUSIONS: ntra-pleural fibrinolytic therapy can potentially cause CAE. Early treatment with oxygen therapy helps in minimizing the morbidity and mortality from CAE. REFERENCE #1: [1] Ishihara, Toru, et al. "Complications of cerebral air embolism associated with pleural lavage for empyema." BMJ Case Reports CP 15.6 (2022): e249618. REFERENCE #2: [2] Patel, S., T. J. Ellis, and R. H. Dougherty. "Air Rises: A Unique Case of Pneumocephalus Secondary to Intrapleural Fibrinolytic Therapy." B46. VASCULAR, PROCEDURAL, AND POST PROCEDURAL COMPLICATIONS. American Thoracic Society, 2022. A2940-A2940. REFERENCE #3: [3] Ohuchi, Masatsugu, et al. "Systemic air embolism during pleural lavage for empyema." General Thoracic and Cardiovascular Surgery 65.10 (2017): 602-604. DISCLOSURES: No disclosure on file for Samantha Barclay No relevant relationships by Nicole Clapp No relevant relationships by Mohammad Jamil No relevant relationships by Meeshal Khan No relevant relationships by Jehanzeb khan No relevant relationships by Bilqees Khanam No relevant relationships by Ajay Nadig No relevant relationships by Eisha Sheikh