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Year : 2018  |  Volume : 14  |  Issue : 7  |  Page : 1650-1654

Cerebral air embolism during percutaneous computed tomography scan-guided liver biopsy

1 Department of Medical Oncology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
2 Department of Neurosurgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China

Date of Web Publication19-Dec-2018

Correspondence Address:
Hao Xu
Department of Neurosurgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_1035_17

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 > Abstract 

Purpose: The objective of the study is to explore the etiology, clinical manifestations, imaging features, diagnosis, treatment, and prognosis of cerebral air embolism complicated computed tomography (CT) scan-guided percutaneous liver biopsy.
Materials and Methods: A case of air embolism was developed in the brain during a CT-guided percutaneous needle biopsy of the liver. In addition, retrospective analysis was performed on the previously reported typical cases of cerebral air embolism secondary to CT-guided percutaneous lung biopsy.
Results: Cerebral air embolism has been recognized as a potentially fatal but extremely rare complication following CT-guided percutaneous liver or lung biopsy. It was usually caused by cough, positive pressure ventilation, incorrect puncture position, repeated punctures, cavity or cyst in the target sites, and vascular inflammatory lesions.
Conclusions: Clinicians should focus on timely and correct diagnosis of this complication during their interventional procedures. The current main treatment for this complication has been hyperbaric oxygen therapy.

Keywords: Cerebral air embolism, hyperbaric oxygen therapy, liver biopsy

How to cite this article:
Sun D, Sui P, Zhang W, Zhang L, Xu H. Cerebral air embolism during percutaneous computed tomography scan-guided liver biopsy. J Can Res Ther 2018;14:1650-4

How to cite this URL:
Sun D, Sui P, Zhang W, Zhang L, Xu H. Cerebral air embolism during percutaneous computed tomography scan-guided liver biopsy. J Can Res Ther [serial online] 2018 [cited 2022 Sep 26];14:1650-4. Available from: https://www.cancerjournal.net/text.asp?2018/14/7/1650/247712

 > Introduction Top

Computed tomography-guided percutaneous thin-needle biopsy is a well established method for diagnosing pathologic conditions. Most practitioners performing such procedures are aware of the common complications of pneumothorax, pulmonary bleeding and hemoptysis. Cerebral air embolism is a infrequently documented condition, but it is serious and often fatal. We report a case of an air embolism in the brain that developed during a CT-guided percutaneous needle biopsy of the liver. The patient was initially diagnosed as acute cerebral infarction, and was treated according to the therapeutic strategy of acute cerebralvascular disease. Fortunately, the outcome was quite satisfactory that the patient gained consciousness in day 4 and discharged uneventfully recovery in day 9 with no other complications. We also summarized the important and relatively interesting clinical case reports of systemic air embolism related to this biopsy technique over the past 20 years. Hopefully, our gathered clinical information and experience would provide some reference and inspiration for clinicians.

 > Case Report Top

We have reported a case of 58-year-old male with physical health in the past who was pathologically diagnosed as small cell lung cancer on March 12, 2016. Enhanced computed tomography (CT) and positron emission tomography/CT indicated the occupation in the S6 segment of liver with undefined nature. After receiving two cycles of etoposide and cisplatin (EP) chemotherapy, partial remission was achieved in the pulmonary lesion of this patient, while no significant variation was observed in the intrahepatic placeholder lesions. There was no surgical contraindication; then, CT-guided percutaneous liver biopsy was performed on this patient to confirm the nature of the liver occupation. The patient laid down on the left lateral position and received local anesthesia with 0.2% lidocaine. A biopsy needle of 16G was punctured under the guidance of CT screen. According to the CT scan during the procedure, the respiratory rate of the patient was obviously increased, while we observed that the biopsy needle was punctured into the right lower lobe of the lung [Figure 1]. When the clinician adjusted the biopsy needle, the patient was found unconscious with no response. Then, the persistent tonic convulsions were observed, and the patients showed severe restlessness. Physical examination revealed binocular gaze and the muscle strength of the left limb was significantly declined to Level I or II. Fortunately, the vital signs of the patient remained stable at that time. Initially, considered as epileptic seizures, we immediately pulled out the needle and gave 10 mg of diazepam by intravenous injection and 250 ml of 20% mannitol by intravenous infusion. However, the above symptoms were not relieved, and then, the patient received an emergency brain CT screen. The results showed no signs of cerebral hemorrhage or significant neoplastic metastasis. Under the consideration of acute cerebrovascular diseases, the patient was administrated with another 10 mg of diazepam being provided by intravenous injection and 100 mg of phenobarbital by intramuscular injection. Epilepsy sustained to develop. After transferring to the Neurology Intensive Care Unit, the patient received propofol, midazolam, haloperidol, and other drugs for sedation; dexmedetomidine for restlessness; and mannitol for intracranial dehydration. One hour after the onset, thrombolytic therapy was performed with 6 mg of alteplase by intravenous injection and another 63 mg within 1 h. Thrombolytic process went smoothly and the muscle strength of the left limb was improved to Level 2 or 3 afterward. The sedation drugs were then gradually reduced. Two days after the surgery, the patient suffered restlessness, binocular right eye gaze, and 38.0° fever. Apart from symptomatic treatment, plavix and risperidone were provided for antiplatelet therapy and mental symptoms, respectively. Spinal puncture showed 210 mmH2O intracranial pressure, without abnormity in cerebrospinal fluid assays. With brain magnetic resonance imaging (MRI) and magnetic resonance angiography, the results showed scattered white matter demyelination changes in the bilateral frontal and parietal lobe, as well as limited artery stenosis and artery sparse in the bilateral distal middle cerebral arteries [Figure 2]. In day 3 after surgery, the conditions of patient were improved, appearing trance and occasional irritability. He could struggle to get up from bed and do both eyes movements, while still no response to questions. Limb muscle tension returned normal and the muscle strength was improved to Level III–IV in the upper left, Level IV+ in the lower left, and Level 5 in the right limbs. The administration of dexmedetomidine was gradually reduced to stop. In day 4, the patient regained consciousness with slow reactions. Both the muscle strength and tension tend normal. In day 5, the patient could answer some simple questions and comprehension, orientation, and memory seemed normal, while computing ability seemed slightly damaged. Irritability occurred in the evening, and the peripherally inserted central catheter was removed by the patient himself. Then, he was put to sleep with olanzapine. In day 6, night irritability was relived and the self-care ability was recovered. Brain enhanced MRI showed abnormal signs in the right frontal cortex, including possible cerebral infarction and white matter demyelination in the bilateral frontal and parietal lobe [Figure 3]. In day 9, the patient achieved general recovery and the drugs were gradually reduced. In day 11, the patient fully recovered and checked out.
Figure 1: (a) Enhanced computed tomography indicating occupation in the S6 segment of the liver with an undefined nature. (b) The needle roadmap before the puncture. (c) The computed tomography scan during the procedure indicated that the biopsy needle was punctured into the right lower lobe of the lung

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Figure 2: Initial magnetic resonance image and angiography (a-c) obtained 24 h after symptom onset and the initial brain diffusion-weighted magnetic resonance images (d-f) showed no obvious abnormalities. Magnetic resonance angiography results (g-i) showed limited artery stenosis and artery sparse in bilateral distal middle cerebral arteries

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Figure 3: Brain enhanced magnetic resonance imaging 6 days after the biopsy (a-c) showing abnormal signs in the right frontal-parietal cortex, as possible cerebral infarction; diffusion-weighted magnetic resonance images (d-f) showing high-density shadow in the bilateral frontal and parietal lobe

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Considering that the patient had no previous medical history, except for malignant neoplasm, the causes contributed to serious cerebrovascular accident during the puncture deserved further investigation. Hence, we gathered the relevant departments for consultation. The results of brain CT were re-read, and the low-density signal in the right sulci was observed when symptoms occurred. Combined the results of brain weighted MRI and CT, the patient was eventually diagnosed as cerebral air embolism [Figure 4]. Currently, the patient completed radiotherapy and chemotherapy in our department and remained stable conditions.
Figure 4: Brain computed tomography fluoroscopic image during the biopsy procedure showing low-density signal in the right sulci when symptoms occurred (a-c). Combined the results of brain weighted magnetic resonance imaging and computed tomography, the patient was eventually diagnosed as cerebral air embolism (d-f)

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 > Discussion Top

CT-guided percutaneous needle biopsy is a common clinical procedure for the diagnosis of various cancer pathological conditions.[1],[2],[3] Cerebral air embolism has been recognized as a potentially fatal but extremely rare complication.[4],[5],[6] Usually, it occurred by excessive lung expansion resulted from low ambient pressure. The incidence of cerebral air embolism has been reported to be 0.02%–0.07%.[2],[7],[8] According to the gathered literature, merely 30 cases have been reported in the past 40 years.[4],[9],[10],[11],[12] Here, the important and relatively interesting clinical case reports of cerebral air embolism complicated CT scan-guided percutaneous needle biopsy are summarized in [Table 1]. However, its incidence might be underestimated because of the missing systemic air in patients without causing cardiac or cerebral symptoms. For the cerebral air embolism occurred during the puncture, the patients would probably suffer from ankylosing or paroxysmal twitch, consciousness loss or headache, dizziness, and nausea.[13],[16] Then, it was accompanied with breathing difficulties, weak breathing, whole-body cyanosis, blindness, limb paralysis or convulsions, and finally shock.[1],[10],[14] According to previous studies, the risk factors that facilitated air entrainment in cerebral air embolism include cachexia, hypovolemia, high-negative intrathoracic pressure, bullous lung disease, inflammation or vascular lesions, fistulas caused by the biopsy needle puncturing the pulmonary veins and alveolus or bronchus containing air, and cough.[5],[13],[15],[16] Poor coagulation was also considered as a risk factor.[13],[17],[18] Currently, literature on the standard treatment of cerebral air embolism has been quite limited. Besides symptomatic treatment and hyperbaric oxygen therapy, the amount of the gas into the brain could be reduced by keeping the head in a lower position.[4],[19],[20],[21] Certainly, prevention deserved more attention in this condition. Patients should suspend breathing whenever being instructed and avoid coughing during the procedure.[10],[12],[15] The number of punctures should be minimized. The duration to introduce needle's explore to air should be as short as possible.[1],[13] By carefully designing the needle path and applying saline or gelatin sponge, the puncture site wound should be immediately closed with either a physician's finger or by the introduction of a biopsy needle.[2],[13],[14] As far as possible, pulmonary vessels and bronchi should be avoided by the needle path.[18],[20],[22]
Table 1: Clinical characteristics of patients with cerebral air embolism complicated percutaneous computed tomography-guided transthoracic biopsy

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Due to the lack of relevant experience and understanding of this complication, the patient was initially diagnosed as acute cerebral infarction. Therefore, this patient was treated according to the therapeutic strategy of acute cerebral vascular diseases. Fortunately, the outcome was quite satisfied that the patient recovered consciousness in day 4 and discharged uneventfully in day 9 without other complications. Although without making timely and accurate diagnosis, the treatments made effects on the recovery of these patients, including reduced air into the brain with sedation and braking position and improved circulation and neuroprotection for decreasing ischemia and hypoxia of the brain cells. Besides, thrombolysis and anticoagulant therapy played important roles throughout this process. Though with high risk, thrombolysis therapy avoided secondary injury caused by the air embolism.

 > Conclusion Top

Because of the low incidence and sudden occurrence of cerebral air embolism, it was hard to avoid missed diagnosis and misdiagnosis for a young physician with limited clinical experience. Experiences in this report would provide references for clinicians in the future.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 > References Top

Kodama F, Ogawa T, Hashimoto M, Tanabe Y, Suto Y, Kato T, et al. Fatal air embolism as a complication of CT-guided needle biopsy of the lung. J Comput Assist Tomogr 1999;23:949-51.  Back to cited text no. 1
Lederer W, Schlimp CJ, Glodny B, Wiedermann FJ. Air embolism during CT-guided transthoracic needle biopsy. BMJ Case Rep 2011;2011. pii: bcr0420114113.  Back to cited text no. 2
Zhu LZ, Yang RJ, Zhu X. Role of inferior phrenic artery in the interventional treatment of lung metastases tumor: A report of 11 cases. J Cancer Res Ther 2018;14:61-7.  Back to cited text no. 3
Wong RS, Ketai L, Temes RT, Follis FM, Ashby R. Air embolus complicating transthoracic percutaneous needle biopsy. Ann Thorac Surg 1995;59:1010-1.  Back to cited text no. 4
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Li W, Man W, Guo H, Yang P. Clinical study of transcatheter arterial chemoembolization combined with microwave ablation in the treatment of advanced hepatocellular carcinoma. J Cancer Res Ther 2016;12:C217-20.  Back to cited text no. 6
Regge D, Gallo T, Galli J, Bertinetti A, Gallino C, Scappaticci E, et al. Systemic arterial air embolism and tension pneumothorax: Two complications of transthoracic percutaneous thin-needle biopsy in the same patient. Eur Radiol 1997;7:173-5.  Back to cited text no. 7
Mansour A, AbdelRaouf S, Qandeel M, Swaidan M. Acute coronary artery air embolism following CT-guided lung biopsy. Cardiovasc Intervent Radiol 2005;28:131-4.  Back to cited text no. 8
Hiraki T, Fujiwara H, Sakurai J, Iguchi T, Gobara H, Tajiri N, et al. Nonfatal systemic air embolism complicating percutaneous CT-guided transthoracic needle biopsy: Four cases from a single institution. Chest 2007;132:684-90.  Back to cited text no. 9
Lattin G Jr., O'Brien W Sr., McCrary B, Kearney P, Gover D. Massive systemic air embolism treated with hyperbaric oxygen therapy following CT-guided transthoracic needle biopsy of a pulmonary nodule. J Vasc Interv Radiol 2006;17:1355-8.  Back to cited text no. 10
Ohashi S, Endoh H, Honda T, Komura N, Satoh K. Cerebral air embolism complicating percutaneous thin-needle biopsy of the lung: Complete neurological recovery after hyperbaric oxygen therapy. J Anesth 2001;15:233-6.  Back to cited text no. 11
Li B, Wang Z, Zhou K, Gao Q, Li X. Safety and feasibility within 24 h of discharge in patients with inoperable malignant lung nodules after percutaneous microwave ablation. J Cancer Res Ther 2016;12:C171-5.  Back to cited text no. 12
Suzuki K, Ueda M, Muraga K, Abe A, Suda S, Okubo S, et al. An unusual cerebral air embolism developing within the posterior circulation territory after a needle lung biopsy. Intern Med 2013;52:115-7.  Back to cited text no. 13
Wu YF, Huang TW, Kao CC, Lee SC. Air embolism complicating computed tomography-guided core needle biopsy of the lung. Interact Cardiovasc Thorac Surg 2012;14:771-2.  Back to cited text no. 14
Ashizawa K, Watanabe H, Morooka H, Hayashi K. Hyperbaric oxygen therapy for air embolism complicating CT-guided needle biopsy of the lung. AJR Am J Roentgenol 2004;182:1606-7.  Back to cited text no. 15
Hokkoku K, Kuwabara M, Chiba T, Kanbayashi T, Ookuma H, Kawamura Y, et al. Cerebral air embolism likely due to pulmonary Mycobacterium avium complex disease. J Neurol Sci 2016;365:188-9.  Back to cited text no. 16
Tabata H, Kitaguchi H, Terajima Y, Shindo K. Cerebral air embolism with pneumomediastinum resulting from emesis: A case report. J Stroke Cerebrovasc Dis 2016;25:e178-80.  Back to cited text no. 17
Kalani MY, Park MS, Kilburg C, Taussky P. Cerebral air embolism treated with endovascular flow reversal and suction aspiration. Interdiscip Neurosurg 2017;10:17-9.  Back to cited text no. 18
Arnold BW, Zwiebel WJ. Percutaneous transthoracic needle biopsy complicated by air embolism. AJR Am J Roentgenol 2002;178:1400-2.  Back to cited text no. 19
Voigt P, Schob S, Gottschling S, Kahn T, Surov A. Systemic air embolism after endoscopy without vessel injury – A summary of reported cases. J Neurol Sci 2017;376:93-6.  Back to cited text no. 20
Mokhlesi B, Ansaarie I, Bader M, Tareen M, Boatman J. Coronary artery air embolism complicating a CT-guided transthoracic needle biopsy of the lung. Chest 2002;121:993-6.  Back to cited text no. 21
Chakravarti R, Singh V, Isaac R, John MJ. Fatal paradoxical pulmonary air embolism complicating percutaneous computed tomography-guided needle biopsy of the lung. Australas Radiol 2004;48:204-6.  Back to cited text no. 22


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]

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