Early View Article: Online published version of an accepted article before publication in the final form.

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1 : Online published version of an accepted article before publication in the final form. Journal Name: Journal of Case Reports and Images in Medicine Type of Article: Clinical Images Title: Cerebral air embolism after central vein catheter removal Authors: Mariana Malheiro, Ana Joao Pissarra, Ana Placido, Ana Martins doi: To be assigned Early view version published: June 22, 2017 How to cite the article: Malheiro M, Pissarra AJ, Placido A, Martins A. Cerebral air embolism after central vein catheter removal. Journal of Case Reports and Images in Medicine. Forthcoming Disclaimer: This manuscript has been accepted for publication. This is a pdf file of the. The is an online published version of an accepted article before publication in the final form. The proof of this manuscript will be sent to the authors for corrections after which this manuscript will undergo content check, copyediting/proofreading and content formatting to conform to journal s requirements. Please note that during the above publication processes errors in content or presentation may be discovered which will be rectified during manuscript processing. These errors may affect the contents of this manuscript and final published version of this manuscript may be extensively different in content and layout than this. Page 1 of 7

2 TYPE OF ARTICLE: Clinical Images TITLE: Cerebral air embolism after central vein catheter removal AUTHORS: Mariana Malheiro 1, Ana Joao Pissarra 1, Ana Placido 1, Ana Martins 1 AFFILIATIONS: 1 MD, Medical Oconlogy Department, Hospital Sao Francisco Xavier, Lisbon, Portugal, marianamalheiro@gmail.com CORRESPONDING AUTHOR DETAILS Mariana Malheiro Rodrigues Lisbon, Portugal, marianamalheiro@gmail.com Short Running Title: Cerebral Air Embolism after CVC Removal Guarantor of Submission: The corresponding author is the guarantor of submission Page 2 of 7

3 TITLE: Cerebral air embolism after central vein catheter removal CASE REPORT A 57-years-old man with metastatic colon cancer and metastatic squamous cell carcinoma of the salivary gland presented to the emergency department with dizziness, nausea and cervicalgia for one week. The brain MRI showed a secondary lesion in the left cerebellar hemisphere, excised without intercurrences in the immediate postoperative period. For purposes of therapeutic administration, a central venous catheter (CVC) was introduced, in the right subclavian vein, before surgery. One week after, when the CVC was withdrawn, the patient presented with involuntary movements, loss of consciousness and left hemiparesis. On neurological examination, he presented with psychomotor lithification, paresis of horizontal conjugated look to the left, discrete pupillary asymmetry, and left members paresis. He was hemodynamically stable, with no signs of other organ damage. Brain CT revealed a bilateral fronto-parietal diffuse cortical acute ischemic cerebral stroke, secondary to air embolism (Figure 1 (A) and (B)). He was immediately placed in Trendelenburg position and a high amount of oxygen was administered. He kept hemodynamically stable, with no further deficits and was then transferred to the neurology department where he begun a physical rehabilitation process with progressive recovery of the neurological deficits. DISCUSSION Air embolism is a rare, usually iatrogenic condition, that can happen following CVC removal [1],[2]. It is a preventable, often undiagnosed but potentially treatable cause of ischemic stroke with a high morbidity and mortality. Symptoms may be unspecific including seizures, loss of consciousness, altered mental status, and hemiparesis/hemiplegia [3]. There are tree mechanisms described: First, there can be a Patent Foramen Oval or an atrial septal defect that could facilitate a paradoxical air embolism into the cerebral arterial tree [1]. Second, it can enter the systemic arterial circulation due to Page 3 of 7

4 incomplete filtering of the air in the normal pulmonary capillaries or in the presence of pulmonary arterial-venous malformation [1]. Third, and the most probable cause in this patient, a retrograde venous cerebral air embolism, that refers to air in the central venous circulation moving in the opposite direction of the venous blood flow, eventually reaching the cerebral vasculature [2]. There are some preventable procedures when removing catheters. It is recommended to keep the patient in a supine position or with their head down or in a Trendelenburg position central. The venotomy place should be below the level of the heart to ensure adequate central venous return. Removal of the catheter should be performed during active expiration. The exit site must be covered with impermeable dressing and pressure applied for 5 10 min. The patient should remain supine for 30 minutes, after central venous access removal [3],[4]. Treatment consists in preventing further air entry, reducing the volume of air entrained, and hemodynamic support(5). The patient should be placed in a Trendelenburg position. If a CV catheter is present, aspiration should be applied in an attempt to remove air. The administration of supplemental oxygen with a high fraction of inspired oxygen (FiO 2 ) is critical [6]. Hyperbaric oxygen therapy (HBO) is not routinely administered in patients with air embolism but is useful severe cases, often those with arterial air embolization [6,7]. When available, it should be administered to patients with hemodynamic or cardiopulmonary compromise, with neurologic deficits, or other evidence of end-organ damage. The use of anticoagulation and glucocorticoids is controversial [6,7]. Morbidity and mortality, which ranges from 48 to 80%, is directly related to volume of air entrainment, rate of accumulation of air, and position of the patient [7]. CONCLUSION Vascular air embolism is a rare and preventable medical event. It can be often fatal and attention to the interventional procedures must be taken. The treatment goal is to prevent the event and there are several measures when disconnecting a CVC. When there is a suspicion of embolic air event immediate treatment should be provided in order to reduce morbidity and mortality. 96 Page 4 of 7

5 CONFLICT OF INTEREST No conflict of interests to declare AUTHOR S CONTRIBUTIONS Ana Pissarra Group1 - Conception and design, Acquisition of data, Analysis and interpretation of data Group 2 - Drafting the article, Critical revision of the article Group 3 - Final approval of the version to be published Ana Placido Group1 - Conception and design, Acquisition of data, Analysis and interpretation of data Group 2 - Drafting the article, Critical revision of the article Group 3 - Final approval of the version to be published Ana Martins Group1 - Conception and design, Acquisition of data, Analysis and interpretation of data Group 2 - Drafting the article, Critical revision of the article Group 3 - Final approval of the version to be published REFERENCES 1. Suri V, Gupta R, Sharma G, Suri K. An unusual cause of ischemic stroke - Cerebral air embolism. Ann Indian Acad Neurol [Internet] Jan [cited 2017 Jun 4];17(1): Available from: 2. Eum DH, Lee SH, Kim HW, Jung MJ, Lee JG. Cerebral air embolism following the removal of a central venous catheter in the absence of intracardiac right-toleft shunting: a case report. Medicine (Baltimore) [Internet] Apr [cited 2017 Jun 4];94(13):e630. Available from: Page 5 of 7

6 McCarthy CJ, Behravesh S, Naidu SG, Oklu R. Air Embolism: Practical Tips for Prevention and Treatment. J Clin Med [Internet] Oct 31 [cited 2017 Jun 4];5(11). Available from: 4. Hsiung G-YR, Swanson PD. Cerebral air embolism after central venous catheter removal. Neurology [Internet] Oct 10 [cited 2017 Jun 4];55(7): Available from: 5. Brouns R, De Surgeloose D, Neetens I, De Deyn PP. Fatal Venous Cerebral Air Embolism Secondary to a Disconnected Central Venous Catheter. Cerebrovasc Dis [Internet] Feb 24 [cited 2017 Jun 17];21(3): Available from: 6. Air embolism - UpToDate [Internet]. [cited 2017 Jun 17]. Available from: embolism treatment&selectedtitle=1~150#h Shaikh N, Ummunisa F. Acute management of vascular air embolism. J Emerg Trauma Shock [Internet] Sep [cited 2017 Jun 17];2(3): Available from: FIGURE LEGEND Figure 1: (A) e (B) - Brain CT Bilateral frontal-parietal diffuse cortical acute ischemic cerebral, secondary to air embolism Page 6 of 7

161 FIGURE 162 163 164 165 166 Figure 1: (A) e (B) - Brain CT Bilateral

7 161 FIGURE Figure 1: (A) e (B) - Brain CT Bilateral frontal-parietal diffuse cortical acute ischemic cerebral, secondary to air embolism. Page 7 of 7

A Rare Case of Cerebral Air Embolism Caused by Pulmonary Arteriovenous Malformation After Removal of a Central Venous Catheter

Case Report This is Advance Publication Article Kurume Medical Journal, 65, 00-00, 2018 A Rare Case of Cerebral Air Embolism Caused by Pulmonary Arteriovenous Malformation After Removal of a Central Venous