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All the Bubbles "Are-Gone": An Unusual Cause of Stroke Post Argon Plasma Coagulation in a Patient With Hereditary Hemorrhagic Telangiectasia (HHT) FREE TO VIEW

Jonathan Wiesen, MD; Ari Wiesen, MD; Wayne Tsuang, MD
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Cleveland Clinic Foundation, Cleveland, OH

Chest. 2014;146(4_MeetingAbstracts):255A. doi:10.1378/chest.1991474
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SESSION TITLE: Critical Care Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Stroke is a common cause of admission to the intensive care unit (ICU).

CASE PRESENTATION: A 79 year old Caucasian male with a past medical history of hereditary hemorrhagic telangiectasia (HHT) complicated by epistaxis and recurrent gastrointestinal bleeding (GIB) necessitating monthly ablation of arterio-venous malformations with argon plasma coagulation (APC) presented to the intensive care unit after failing to awake post esophagogastroduodenoscopy (EGD). The patient had undergone EGD with APC of multiple bleeding arterio-venous malformations (AVM) in the stomach and duodenum. Post procedure he remained unresponsive and computed tomography (CT) of the head demonstrated a punctate air embolus in the right frontal hemisphere. Magnetic resonance imaging (MRI) of the brain demonstrated multiple small acute infarcts in the right frontal, left parietal and left occipital lobes secondary to multiple air emboli. Esophagogram was normal without evidence of an esophageal perforation. Echocardiogram with bubble study showed no intracardiac shunt. The patient was placed on 100% FiO2 for 24 hours to accelerate air embolism absorption. He slowly recovered neurological function and strength and was discharged to a rehabilitation facility.

DISCUSSION: Argon has been implicated as the source of air emboli in many different procedures, including non-surgical interventions such as bronchoscopy and hepatic ablations. Air embolism after EGD is extremely rare. Presumably, especially in a patient with multiple AVMs and ectatic vasculature, argon can be released systemically during the APC procedure and cause systemic embolism. Hyperoxia or hyperbaric oxygen therapy can accelerate resolution of the air emboli.

CONCLUSIONS: Although most strokes are ischemic or thromboembolic in nature, air emboli can be an uncommon cause of stroke after invasive procedures or in patients with an intra-cardiac shunt.

Reference #1: Reddy et al. Gas embolism following bronchoscopic argon plasma coagulation: a case series. 2008;134(5):1066-9.

DISCLOSURE: The following authors have nothing to disclose: Jonathan Wiesen, Ari Wiesen, Wayne Tsuang

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