A Cerebral Air Embolism after Endoscopic Treatment

A 77-year-old man with liver cirrhosis was admitted to our hospital in 2015. He was unconscious and his Glasgow Coma Scale (GCS) score was 10. The Hb level was 3.5 mg/ dL. Contrast CT showed esophageal varices and atrophy of liver, these findings indicated a suspicion of liver cirrhosis. We considered that the varix rupture and the resulting hemorrhagic shock were the main cause of the patient’s unconsciousness. We performed gastroduodenoscopy, leading to endoscopic variceal ligation (EVL) of the two varices. The procedure ended successfully, and the patient returned to the ER. Shortly after returning to the ER, the patient suddenly became unresponsive. His GCS score dropped to 7. Head CT showed pneumocephalus and a suspected air embolism of the right hemisphere (Left Picture). Hyperbaric oxygen therapy was performed seven times, but his GCS did not improve above 9. CT on day 40 showed a massive infarction of the right hemisphere. (Right Picture). In this case, the patient fortunately survived, but he was left with major disabilities and was no longer independent. Transthoracic echocardiography did not show any evidence of a patent foramen ovale. The mechanism of air embolism after EVL remains to be elucidated, but mucosal damage realted to invasive endoscopic procedures is thought to be the major cause of air embolism.