Cerebral air embolism after indwelling pleural catheter insertion in a chronic hydropneumothorax secondary to epithelioid mesothelioma

Our plain-English summary of Cerebral air embolism after indwelling pleural catheter insertion in a chronic hydropneumothorax secondary to epithelioid mesothelioma, by D.M.C. Jayawardena, R.K. Panchal, S. Agrawal, et al (BMJ Case Reports, 2021).

The study

• Authors: D.M.C. Jayawardena, R.K. Panchal, S. Agrawal, I. Das
• Journal: BMJ Case Reports
• Published: 2021;14(7)
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

A 75-year-old man with a history of epithelioid mesothelioma and a right-sided indwelling pleural catheter (IPC) presented with a history of a purulent fluid drainage via the IPC. The pleural fluid cultured Klebsiella oxytoca and Enterococcus faecalis He was treated with a course of oral fluoroquinolone followed by uneventful IPC replacement. One and half hours postprocedure, the patient had a witnessed drop in conscious level accompanied by seizure like activity. Acute stroke was suspected and a CT head was performed. CT head revealed multiple serpiginous pockets of air along the cerebral fissure, with features that were highly suggestive of cerebral air embolism and multiple wedge-shaped areas of infarction involving the cerebral hemispheres. Further imaging revealed satisfactory position of the replaced IPC. The patient was admitted to the intensive care unit for high flow oxygen therapy and head down ventilation. However, his condition deteriorated and he died later.

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In plain English

This case report described one 75-year-old man with epithelioid mesothelioma who had a right-sided indwelling pleural catheter, a tube left in the chest to drain fluid. The article does not discuss asbestos exposure. Fluid draining through the catheter had become purulent and grew the bacteria Klebsiella oxytoca and Enterococcus faecalis. He was treated with the antibiotic ciprofloxacin, and the catheter was later replaced under local anaesthesia without immediate problems. One and a half hours after the procedure his level of consciousness suddenly dropped, with seizure-like activity, and his Glasgow Coma Scale score was 4. A CT scan of the head showed pockets of air along the cerebral fissure, highly suggestive of cerebral air embolism (air blocking blood flow in the brain), and areas of infarction in the cerebral hemispheres. A chest CT showed the new catheter was satisfactorily placed. He received high flow oxygen in intensive care. Because of his poor physiological reserve he was not considered for mechanical ventilation or hyperbaric oxygen, and he died 6 days later. The authors stated that the cause was not clear but was likely a pulmonary venous air embolism. They also stated that this complication had not previously been reported after this procedure.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: One 75-year-old man with epithelioid mesothelioma and a right-sided indwelling pleural catheter, treated at Glenfield Hospital, Leicester, UK
• Exposure: The article does not mention asbestos or any occupational exposure. The event described followed replacement of an indwelling pleural catheter under local anaesthesia and mild sedation.
• Main results:
  • Before the replacement, the pleural fluid grew Klebsiella oxytoca and Enterococcus faecalis, and the patient was treated with ciprofloxacin
  • One and a half hours after the procedure, the patient had a witnessed sudden drop in conscious level with seizure-like activity
  • The patient's Glasgow Coma Scale score was 4
  • CT head showed multiple pockets of air along the cerebral fissure, highly suggestive of embolism
  • CT head also showed multiple wedge-shaped areas of infarction involving the cerebral hemispheres
  • CT chest showed satisfactory positioning of the replaced catheter
  • The patient was admitted to intensive care for high flow oxygen therapy
  • The patient was not considered for mechanical ventilation or hyperbaric oxygen therapy because of poor physiological reserve due to mesothelioma and the hydropneumothorax
  • The patient died 6 days later
• The authors' conclusion: The authors concluded that iatrogenic cerebral air embolism is extremely rare in pleural interventions but carries significant mortality and morbidity. They considered it likely that this patient had a pulmonary venous air embolism. They stated that this complication had not previously been reported after indwelling pleural catheter insertion.
• Limitations the authors state:
  • The authors stated that the cause of the air embolism in this patient was not clear, as there were no immediate complications during the procedure and imaging showed no trauma to the lung or major blood vessels
  • The proposed mechanism, involving chronic changes in the chest after earlier mesothelioma surgery, was presented by the authors as a hypothesis

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Indwelling Pleural Catheter, Epithelioid, Mesothelioma, Supplemental Oxygen.

Related studies

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• Aggressive versus symptom-guided drainage of malignant pleural effusion via indwelling pleural catheters (AMPLE-2): an open-label randomised trial — S. Muruganandan, M. Azzopardi, et al. (2018)
• Intrapleural Fibrinolysis for the Treatment of Indwelling Pleural Catheter-Related Symptomatic Loculations: A Multicenter Observational Study — R. Thomas, F. Piccolo, et al. (2015)
• Catheter tract metastasis associated with indwelling pleural catheters — R. Thomas, C.A. Budgeon, et al. (2014)
• Safety of indwelling pleural catheter use in patients undergoing chemotherapy: a five-year retrospective evaluation — C.C. Hak, P. Sivakumar, et al. (2016)
• MesoTRAP: a feasibility study that includes a pilot clinical trial comparing video-assisted thoracoscopic partial pleurectomy decortication with indwelling pleural catheter in patients with trapped lung due to malignant pleural mesothelioma designed to address recruitment and randomisation uncertainties and sample size requirements for a phase III trial — C. Matthews, C. Freeman, et al. (2019)

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