Left hemiparesis during es-ophagogastroduodenoscopy: A unique syndrome due to cerebral air embolism

摘要

Sir Esophagogastroduodenoscopy (EGD) is a widely performed procedure for evaluating the upper gastrointestinal tract. It is relatively safe and without significant complications. Neurological adverse events are infrequent and mostly due to sedating medications used during the procedure. Ischemic stroke as a complication is extremely rare and results from cerebral air embolism. A literature review reveals only nine such cases associated with EGD [Table 1]. A 71-year-old man with history of stage IV squamous cell cancer of the left tonsil undergoing chemotherapy and radiotherapy had an elective EGD for evaluation of esophageal abnormalities seen on positron emission topography (PET) scan. EGD was performed under conscious sedation through a peripheral line. During the procedure, the patient was placed in the left lateral position, and an Olympus GIF-160 forward-viewing video-endoscope was used. A small ulcer was seen in the esophagus, and the biopsies were taken from the esophagus and stomach. A 1-cm arterio-venous malformation was seen in the bulb of the duodenum, which was ablated using a gold probe. Rest of the duodenum was normal. Immediately after the procedure, the patient was unable to move the left side. Examination revealed left hemiparesis, left lower facial weakness, decreased mentation and respiratory distress. Computerized tomography (CT) scan of the head revealed multiple air bubbles in the right middle cerebral artery territory [Figure la]. Radiographic imaging of the chest did not reveal mediastinal or subcutaneous air. He subsequently became more lethargic and developed tonic-clonic seizure and respiratory failure requiring ventilatory support. He was treated with 100% oxygen. Phenytoin was started for seizure prophylaxis. A follow-up CT scan of the head showed evolving ischemic infarct in the right frontoparietal lobe and resolution of intravascular air [Figure 1b]. Echocardiogram with bubble study failed to demonstrate a patent foramen ovale (PFO...