Cerebral air embolism as a complication of upper GI endoscop
Cerebral arterial gas embolism (CAGE) is a rare complication but can occur after many common invasive medical and surgical procedures including upper endoscopy.

Cerebral air embolism due to upper endoscopy without major vessel injury is extremely rare. Hyperbaric oxygen treatment (HBOT) is the only definite treatment for CAGE.

The purpose of this article, published in the Clinical Case Reports is to highlight this unusual, but potentially lethal, complication of upper gastrointestinal endoscopy. The authors present a case of severe cerebral air embolism with initial unconsciousness and surprisingly good outcome correlated to repeated HBOT and 2 weeks of diligent neurointensive care.

A 42‐year‐old healthy man, with a previous episode of food impaction and increased number of eosinophils in esophageal biopsies taken during an index upper endoscopy 6 weeks earlier, underwent outpatient control gastroscopy after receiving proton pump inhibitor treatment. The upper endoscopy was performed under conscious sedation with midazolam, with a standard video endoscope and the air pressure setting on the video processor at “medium.”

Biopsies from distal, middle, and proximal esophagus were taken according to standard protocol. At the end of the 7‐minute‐long procedure, just after biopsies from proximal esophagus was taken, the patient's heart rate decreased to 46, the oxygen saturation decreased to 90%, and he developed generalized tonic‐clonic seizures.

The endoscope was rapidly withdrawn, and the oxygen saturation and heart rate normalized spontaneously. However, the patient was unresponsive despite reversal with flumazenil. While hemodynamically and respiratory stable, he remained unresponsive, Glasgow Coma Scale (GCS 3), with pupils midsize, equal, and reactive to light, and a negative Babinski sign.

An immediate computed tomography (CT) scan 30 minutes postinitial symptoms revealed massive air embolism in the right hemisphere. The radiologists first suspected infarctions, which was later modified. A complementing CT angiography (CT‐AI) was performed 70 minutes after the initial CT scan to rule out differential diagnoses, and the delay was due to recurrent seizure and intubation. The most striking finding was complete resolution of air in the vessels.

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