D110-08 Cerebral Air Embolism Following Robotic-Assisted Bronchoscopy

Abstract Cerebral air embolism (CAE) is a rare cause of ischemic stroke, typically iatrogenic in origin, in which gas bubbles introduced directly to the vasculature reach the cerebral circulation, leading to obstruction of perfusion with resultant infarction. Although typically associated with catheterization or surgical procedures, there have been isolated cases reported of CAE following transbronchial and endobronchial biopsy. We present a novel case of CAE following robotic-assisted bronchoscopy (RAB). A 77-year-old female with history of non-small cell lung cancer presented to the ICU after undergoing RAB for evaluation of new left hilar mass. Following the procedure, she experienced delayed emergence from anesthesia and new neurologic findings, including flexor posturing of the left upper and lower extremities, and anisocoria with fixed pupils. Computerized tomography (CT) of the head obtained during stroke alert revealed new hypodensity concerning cerebral air embolism. Head and neck CT angiography re-demonstrated hypodense lesion, without evidence of large vessel occlusion. Transthoracic echocardiography with bubble study did not demonstrate atrial septal defect (ASD) or patent foramen ovale (PFO). Patient underwent hyperbaric oxygen therapy (HBOT), although began to exhibit seizure-like activity shortly afterwards. EEG demonstrated right temporal epileptiform discharges. MRI revealed bilateral embolic infarcts, and right-sided cortical restricted diffusion. With poor neurological prognosis, patient’s family elected to pursue hospice. CAE may occur through introduction of air into the venous system, which then paradoxically reaches the arterial vasculature through a cardiac opening before embedding in the brain, or via direct connection to the arterial vasculature. Bronchoscopy contains several possible means through which direct arterial insult may occur, often due to communication with pulmonary vasculature within the parenchyma leading to the left heart system. In the case presented here, RAB was utilized, which involves a uniquely flexible robotic arm to access more distal pulmonary lesions. The most common method involves pushing air through a syringe to “stent open” these highly vascularized distal airways to allow for instrumentation. Higher pressures used to manipulate the airways may damage delicate structures, potentially leading to alveolar or pulmonary vasculature rupture, and unintentionally allowing for air introduction. As a potentially fatal outcome of minimally invasive interventions, high index of suspicion for CAE should be maintained in the post-procedural period for patients with new neurologic deficits. As the first reported case of CAE associated with RAB, awareness of this potential complication is critical for ensuring timely initiation of appropriate management. This abstract is funded by: None