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A 71-year-old woman with stage IV lung adenocarcinoma underwent computed tomography (CT)-guided percutaneous needle biopsy of a right lower lobe lesion complicated by acute change in mental status and seizures. CT of her chest showed ipsilateral hemopneumothorax (Figure 1); loss of gray–white differentiation, cytotoxic edema, and diffuse gas attenuation in the right cerebral and cerebellar subarachnoid spaces were found by CT of her head (Figure 2). Tube thoracostomy was performed, but the patient’s condition worsened, and she ultimately died of status epilepticus.
Figure 1. Procedural computed tomography (CT). (A) Noncontrasted CT of the chest during CT-guided transthoracic needle aspiration showing transthoracic needle insertion point (arrowhead) for aspiration biopsy. (B) Immediate postbiopsy image demonstrates development of new hemothorax (lower arrowhead) and pneumothorax (upper arrowhead) ipsilateral to the biopsy site.
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Figure 2. Post-procedural computed tomography (CT) of the patient’s head. Noncontrasted CT of the head performed just after CT-guided transthoracic needle aspiration after apparent generalized tonic-clonic seizure demonstrates diffuse air attenuation in the intergyral subarachnoid space (arrowheads), predominantly in the right cerebral hemisphere, with associated loss of white–gray differentiation and early cytotoxic edema.
[More] [Minimize]Because of the proximity of the pleural and paraspinal spaces, subarachnoid-pleural fistulas can occur with spinal or thoracic instrumentation or spontaneously as a result of invasive malignancy (1, 2). Two possible mechanisms of death in this case include rapid influx of air into the subarachnoid space via a subarachnoid-pleural fistula or arterial air embolism; either of these may cause neuronal cytotoxicity and cerebral dysfunction (3, 4). Post-procedural CT scans did not demonstrate air in transit to support one mechanism over another.
Despite these uncertainties, it is evident that complications of CT-guided lung biopsy led to acute pneumocephalus, resulting in cerebral injury, status epilepticus, and death. The patient’s tumor burden might have disrupted anatomical barriers, facilitating the introduction of air into either the intercostal perineurium or the pulmonary vessels. Some of the results of these studies were previously reported in the form of an abstract presented at the American Thoracic Society 2018 International Conference (5).
| 1. | Ialongo P, Ciarpaglini L, Tinti MD, Suadoni MN, Cardillo G. Systemic air embolism as a complication of percutaneous computed tomography guided transthoracic lung biopsy. Ann R Coll Surg Engl 2017;99:e174–e176. |
| 2. | Shamji MF, Sundaresan S, Da Silva V, Seely J, Shamji FM. Subarachnoid-pleural fistula: applied anatomy of the thoracic spinal nerve root. ISRN Surg 2011;2011:168959. |
| 3. | Sherer DM, Onyeije CI, Yun E. Pneumocephalus following inadvertent intrathecal puncture during epidural anesthesia: a case report and review of the literature. J Matern Fetal Med 1999;8:138–140. |
| 4. | Shih CC, Tsai SH, Liao WI, Wang JC, Hsu CW. Successful treatment of epidural anesthesia-induced severe pneumocephalus by hyperbaric oxygen therapy. Am J Emerg Med 2015;33:1116, e1-3. |
| 5. | Pisano C, O’Connor J, Krick S, Russell D. A fatal case of pneumocephalus during CT guided lung biopsy [abstract]. Am J Respir Crit Care Med 2018;197:A4033. |
Author Contributions: Directly provided patient care in this case: C.P., J.O’C., and S.K. Drafted and edited manuscript: C.P., J.O’C., S.K., and D.W.R. Drafted images: C.P. and D.W.R.
Originally Published in Press as DOI: 10.1164/rccm.201902-0280IM on February 12, 2020
Author disclosures are available with the text of this article at www.atsjournals.org.
