Stroke like symptoms following a CT-guided lung biopsy: Perhaps a more common problem than previously realized

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Catherine Hill
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1 Stroke like symptoms following a CT-guided lung biopsy: Perhaps a more common problem than previously realized ACP Resident Meeting 2016 Katie Kaput D.O PGY-2 Saint Joseph Hospital/National Jewish Health

2 CASE An 80-year-old female with a past medical history of HTN, dyslipidemia and a 50 pack-year smoking history was referred for a CT-guided lung biopsy of a 3.5 x 2.7 cm cavitary lung lesion.

3 CASE Target lesion was localized. A total of three biopsies were taken with a coaxial 19-gauge introducer and 20-gauge Cook Quick-core biopsy device. Patient tolerated the procedure well. 1 hour and 45 minutes after the procedure she developed dysarthria, acute onset of left sided hemiparesis and right gaze preference. Stroke protocol was initiated.

4 PHYSICAL EXAM VS: 97 F (36.1 C), 142/65, 60 bpm, RR 20, 100% on RA. Neurological exam: Mental Status: A&Ox3, failed object identification Speech: Dysarthric with word finding difficulties CN: PERRLA, CN II-XII intact Tone: Increased tone in LUE and LLE Sensation: Light touch sensation impaired in LUE and LLE Strength: Strength 1/5 in LUE and LLE. Strength 5/5 in RUE and RLE Reflexes: Reflexes brisk Glucose: 87 mg/dl

5 CT NON CONTRAST

6 HOSPITAL COURSE Status epilepticus requiring AEDs. Extensive DVT started on anticoagulation. Difficulty in maintaining nutrition for which a percutaneous gastrostomy tube was placed. Persistent left sided hemiparesis requiring rehab and extensive therapy. Significant cognitive and speech deficits. Currently living in a group home.

7 COMPLICATIONS OF LUNG BIOPSY Reported Complications: Pneumothorax Most common Hemoptysis Seeding of the biopsy tract Air embolism Reported incidence of 0.07% + additional case reports Death

8 EPIDEMIOLOGY RARE, but perhaps underestimated. No standard way of defining or reporting cases. Incidence may be underestimated by missing systemic air embolism in the absence of severe neurologic or cardiac sequelae.

9 A retrospective observational study of 610 patients who underwent percutaneous lung biopsy between 2007 and 2009 were analyzed and CT scans were examined retrospectively for air. Radiologic incidence: 3.8% Clinically apparent incidence: 0.49% Mortality: 0.16%.

10 PATHOPHYSIOLOGY Three postulated mechanisms: Placement of the needle in a pulmonary vein. Formation of a bronchialvenous fistula with air passing into the pulmonary vein if the alveolar or the venous pressure is too low. Passage of air via the pulmonary capillary bed from the pulmonary artery into the pulmonary venous system.

11 RISK FACTORS Coaxial biopsy system: Outer cannula is open to the air for a fraction of a second. Number of biopsies: If more biopsy specimens are taken then the cannula is open to air for a few seconds. Cystic or cavitary lesions: If the needle is not properly placed air can be introduced.

12 WHY DOES IT MATTER? Lung cancer is the leading cause of cancer death worldwide. The NLST showed that screening with low dose CT had a 20% relative reduction in lung cancer mortality USPSTF recommends annual screening with low dose CT scan in adults aged who have a 30 pack year smoking history of currently smoke or have quit within the past 15 years.

13 MORE COMMON THAN REALIZED CT-guided percutaneous lung biopsy is increasingly being used to investigate worrisome pulmonary lesions. Screening in a high risk population = high rate of positive examinations. Creating a large reservoir of patients at risk. Bottom line: As the number of biopsies increases, so too may this complication.

14 SUMMARY: Air embolism is a rare entity that may become more common with time. As this dreaded complication may become more common in our everyday practice we should work diligently: Recognize the condition Create standardized protocols Develop sound management plans

15 SOURCES Gernot Rott and Frieder Boecker. Influenceable and avoidable risk factors for systemic air embolism due to Percutaneous CT-Guided Lung Biopsy: Patient Positioning and Coaxial Biopsy Technique Case Report, Systematic Literature review, and a Technical Note. Radiology Research and Practice. Volume 2014 (2014). M Ruparel, SL Quaife, N Navani, et al. Pulmonary nodules and CT screening: the past, present and future. Thorax 2016, 71 (4): M Freund, J Peterson, K Goder, et al. Systemic air embolism during percutaneous core needle biopsy of the lung: frequency and risk factors. BMC Pulmonary Medicine T Hiraki, H. Fujiwara, J Sakurai, et al. Nonfatal Systemic Air Embolism Complicating Percutaneous CT-Guided Transthoracic Needle Biopsy: Four cases from a single institution. CHEST journal.publications.chestnet.org/mobile/article.aspx?articleid= The National Lung Screening Trial Research Team. Reduced Lung-Cancer Mortality with Low dose CT Screening. N Engl J Med

16 QUESTIONS Thank you! Dr. Katie Kaput D.O

Lung Cancer Screening

Lung Cancer Screening Steven Leh, MD, FCCP Diplomat of the American Association for Bronchology and Interventional Pulmonology Aurora Medical Group Pulmonary and Sleep Medicine February 10, 2018 Disclosures