Coronary and cerebral air embolism: a rare complication of computed tomography-guided transthoracic lung biopsy.

A 71-year-old man with a history of excessive smoking was evaluated for an abnormal chest X-ray. He had no angina and no risk factors for coronary artery disease. Considering a high probability of lung cancer in this patient, computed tomography-guided transthoracic lung biopsy was performed by an experienced radiologist. A co-axial 18-gauge needle system was used to enter the lung and two core biopsy samples were obtained. During the procedure the patient was asked to inhale in order to reach the lesion. After the biopsy he developed mild haemoptysis followed by rapid loss of consciousness. After a couple of seconds the patient regained consciousness, was asymptomatic and did not show any signs of respiratory or haemodynamic complications. However, the ECG showed ST-segment elevation in leads I, II, aVL, aVF and V3-6 without reciprocal ST-segment depression suggestive of an acute myocardial infarction involving the distributions of more than one coronary artery (Fig. 1c). Review of the multi-slice CT images showed a mild pneumothorax, pulmonary haemorrhage, and air bubbles in both the circumflex coronary artery and descending aorta, diagnostic of an air embolism of the arterial system (Fig. 1a, b). He was placed in a mild Trendelenburg position and was administered 100 % high-flow non-rebreathing oxygen. Anticoagulation therapy was not initiated due to the pulmonary haemorrhage. Electrocardiography showed complete resolution of the ST-segment elevation after 20 min. However, 3 h later he developed seizures likely due to air embolisation to the cerebral circulation. A subsequent blood test showed cardiac troponin I elevation of 11.0 μg/l, whereas echocardiography demonstrated hypokinesis in the distal inferior and anteroseptal regions. The patient was eventually discharged after 1 week without any cardiac, pulmonary or neurological symptoms.