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Washington University Experience | VASCULAR | Infarct - Air Embolism | 2A0 Case 2 History
Case 2 History ---- The patient was a 66 year-old man with stage IV mantle cell lymphoma s/p multiple rounds of chemotherapy and stem cell transplant in December 2012 and was currently in remission. His other pertinent medical history included atrial fibrillation and diabetes mellitus type 2. The patient presented with multiple bilateral strokes in January 2013 secondary to air emboli resulting from manipulation of his chemotherapy port earlier that day. Per report, the patient became unresponsive with eyes fixed and deviated to the left after the port was flushed with heparin. The patient experienced right hemiparesis which rapidly progressed to total paralysis. A CT performed 30 minutes after onset showed "a moderate amount of intravascular intracerebral air". The radiological findings suggested that the location of these air emboli was likely within cerebral veins. No large or central arterial air emboli were detected. There was no reported evidence of aneurysm, vascular malformation, or hemorrhage. The patient was transferred to St. Luke's hospital for hyperbaric oxygen treatment for 2 hours and returned to BJH with no significant improvement on exam. A transthoracic echocardiography on 1/17/2013 showed a positive bubble study c/w a small patent foramen ovale. Venous access port evaluation on 1/18 showed "the tip of the catheter to be wedged within a superior intercostal vein. The catheter is definitely not intra-arterial". MRI performed on 1/18/2013 showed "extensive acute/subacute infarction involving both frontal lobes, right caudate nucleus, left dorsal medulla, left inferior cerebellum, and right inferior vermis (infarcts involved arterial distribution: of both anterior cerebral arteries and middle cerebral arteries, bilaterally, and the left posterior-inferior cerebellar artery). This was thought to be consistent with patient's history of air embolism. At this time, the family and the clinical team decided to pursue comfort care only. ---- At autopsy, the brain weight was 1420 g and the heart showed a patent foramen ovale.
