Low Pneumoperitoneum Pressure Reduces Gas Embolism During Laparoscopic Liver Resection: A Randomized Controlled Trial.

OBJECTIVE: To compare the effect of low and standard pneumoperitoneal pressure (PP) on the occurrence of gas embolism during laparoscopic liver resection (LLR). BACKGROUND: LLR has an increased risk of gas embolism. Although animal studies have shown that low PP reduces the occurrence of gas embolism, clinical evidence is lacking. METHODS: This parallel, dual-arm, double-blind, randomized controlled trial included 141 patients undergoing elective LLR. Patients were randomized into standard ("S," 15 mm Hg; n = 70) or low ("L," 10 mm Hg; n = 71) PP groups. Severe gas embolism (≥ grade 3, based on the Schmandra microbubble method) was detected using transesophageal echocardiography and recorded as the primary outcome. Intraoperative vital signs and postoperative recovery profiles were also evaluated. RESULTS: Fewer severe gas embolism cases (n = 29, 40.8% vs n = 47, 67.1%, P = 0.003), fewer abrupt decreases in end-tidal carbon dioxide partial pressure, shorter severe gas embolism duration, less peripheral oxygen saturation reduction, and fewer increases in heart rate and lactate during gas embolization episodes was found in group L than in group S. Moreover, a higher arterial partial pressure of oxygen and peripheral oxygen saturation were observed, and fewer fluids and vasoactive drugs were administered in group L than in group S. In both groups, the distensibility index of the inferior vena cava negatively correlated with central venous pressure throughout LLR, and a comparable quality of recovery was observed. CONCLUSIONS: Low PP reduced the incidence and duration of severe gas embolism and achieved steadier hemodynamics and vital signs during LLR. Therefore, a low PP strategy can be considered a valuable choice for the future LLR.

Hepatic portal venous gas: A case report and analysis of 131 patients using PUBMED and MEDLINE database.

OBJECTIVE: Hepatic portal pneumatosis has a high mortality rate, and whether surgical intervention is necessary remains controversial. This experiment retrospectively analyzed the etiology, treatment methods and prognosis of adult patients with hepatoportal pneumocele to provide a theoretical basis for the treatment of this disease. METHODS: We analyzed the clinical symptoms and post-treatment of a 43-year-old male patient with HPVG admitted to hospital. We retrieved adult non-iatrogenic HPVG cases with complete clinical data in PUBMED,  and MEDLINE and other databases were retrieved for analysis, and summarized the pathogenesis, clinical symptoms, pathogenesis, pathogenesis and prognosis of different treatment schemes were summarized. RESULTS: The main etiology of HPVG are intestinal ischemia (27%), severe enteritis/intestinal perforation/intestinal fistula (16%), intestinal obstruction (7%), abdominal infection (7%), gastric diseases (11%), appendicitis and its complications (5%), acute hemorrhage or necrotizing pancreatitis (5%), Crohn's disease and its complications (4%), trauma (traffic accidents, falls) (2%), diverticulitis and perforation (6%), nephrogenic diseases (4%), spontaneous pneumohepatic portal vein (2%), other reasons (4%). And after analysis, we found that the survival rate of patients treated by surgery was 40.5% and the mortality rate was 19.1%, the difference between the two was significant. CONCLUSIONS: Etiology should be actively explored and surgical treatment is necessary.

Enhancing vigilance for cerebral air embolism after pneumonectomy: a case report.

BACKGROUND: Vascular air embolism (VAE) is a rare but important complication that has not been paid enough attention to in the medical process such as surgery and anesthesia. CASE PRESENTATION: We report for the first time that a 54-year-old male patient with central lung cancer developed severe complications of CAE after right pneumonectomy. After targeted first-aid measures such as assisted breathing, mannitol dehydration and antibiotic treatment, the patient gradually improved. The patient became conscious at discharge after 25 days of treatment but left limb was left with nerve injury symptoms. CONCLUSION: We analyzed the possible causes of CAE in this case, and the findings from this report would be highly useful as a reference to clinicians.

Estimating Inert Gas Bubbling from Simple SCUBA Diving Parameters.

Inert gas bubbles frequently occur in SCUBA divers' vascular systems, eventually leading to decompression accidents. Only in professional settings, dive profiles can be adjusted on individual basis depending on bubble grades detected through ultrasonography. A total of 342 open-circuit air dives following sports diving profiles were assessed using echocardiography. Subsequently, (Eftedal-Brubakk) bubble grades were correlated with dive and individual parameters. Post-dive cardiac bubbles were observed in 47% of all dives and bubble grades were significantly correlated with depth (r=0.46), air consumption (r=0.41), age (r=0.25), dive time (r=0.23), decompression diving (r=0.19), surface time (r=- 0.12). Eftedal-Brubakk categorical bubble grades for sports diving with compressed air can be approximated by bubble grade = (age*50-1 - surface time*150-1+maximum depth*45-1+air consumption*4500-1)2 (units in years, hours, meter, and bar*liter; R2=0.31). Thus, simple dive and individual parameters allow reasonable estimation of especially relevant medium to higher bubble grades for information on relevant decompression stress after ascent. Echo bubble grade 0 is overestimated by the formula derived. However, echo might fail to detect minor bubbling only. The categorical prediction of individual decompression stress with simple bio and dive data should be evaluated further to be developed towards dive computer included automatic ex-post information for decision-making on individual safety measures.

Venous air embolism: artefactual air entrapment and autopsy technique.

Venous air embolism (VAE) is a rare cause of death for which special procedures are needed for autopsy diagnosis. The current one of choice was devised by Richter in 1905 to prevent introduction of gas into the right heart while opening the thorax. We could find no published data demonstrating that that this occurs during standard autopsy technique. Two scenarios were investigated. In the first, the study group included cases using the traditional method to open the thoracic cage; in the control group, Richter's method was used. Gas was collected under water and measured in a calibrated tube. The second scenario involved cases in which an intracardiac catheter was present at autopsy. In these, 50 mL of air was injected prior to chest opening and the amount of intracardiac air was measured. The first (non-injected) study and control groups consisted of 28 and 26 cases, respectively. Gas was identified in 3 cases (10%) in the study group and 2 cases (7%) in the control group. In the ten injected cases, there was a significant difference in the amount of the gas recovered (10 mL in the standard cases and 30 mL in the Richter group). No significant artifactual gas entrapment occurs in the right heart using the standard autopsy technique. However, it is possible that this technique may cause loss of intracardiac gas and if there is a clinical suspicion of VAE, Richter's technique should be used.

Venous Gas Embolism during Hysteroscopic Endometrial Ablation: Report of 5 Cases and Review of the Literature.

STUDY OBJECTIVE: To highlight the circumstances, presentation, and treatment of venous gas embolism (VGE) and provide guidance and propose potential changes in surgical practice and perioperative monitoring to minimize the adverse consequences and sequalae of this potentially serious complication. DESIGN: A case series. SETTING: A university-affiliated teaching hospital. PATIENTS: Five women developed VGE during hysteroscopic endometrial ablation. INTERVENTIONS: From 1990 through 2014, the principle author (G.A.V.) performed 5249 primary and 458 repeat hysteroscopic endometrial ablations under general anesthesia using a monopolar 26F (9-mm) resectoscope connected to a peristaltic pump-driven active inflow and outflow irrigation and distension system (1.5% glycine) and an 8-mm monopolar loop electrode at a 120-W continuous (cut) and/or a 3- to 5-mm rollerball interrupted (coagulation) waveform or a combination of them. MEASUREMENTS AND MAIN RESULTS: Among 5707 procedures, we encountered 5 (0.09%, 1/1140) incidents of VGE during primary ablations. All patients exhibited the same symptoms of ventilatory and hemodynamic decompensation, beginning with a reduction in end-tidal carbon dioxide and arterial oxygen desaturation. All patients recovered after immediate cessation of the surgery and resuscitation including ventilatory support with 100% O2 and intravenous fluids. CONCLUSIONS: Although entrainment of some air/gas bubbles is common during hysteroscopy, life-threatening/fatal VGE is rare (1/1140 cases). Situational awareness and strict adherence to certain principles including understanding the conditions, prerequisites, and pathophysiology of VGE; attention to surgical principles and operative technique; close communication with the anesthesiologist; and early therapeutic intervention are of paramount importance to avoid this rare but potentially serious complication.

Clinical features of patients with hepatic portal venous gas.

BACKGROUND: Hepatic portal venous gas (HPVG) is a rare clinical condition that is caused by a variety of underlying diseases. However, the factors that would permit accurate identification of bowel ischemia, requiring surgery, in patients with HPVG have not been fully investigated. METHODS: Thirty patients that had been diagnosed with HPVG using computed tomography between 2010 and 2019 were allocated to two groups on the basis of clinical and intraoperative findings: those with (Group 1; n = 12 [40%]) and without (Group 2; n = 18 [60%]) bowel ischemia. Eleven patients underwent emergency surgery, and bowel ischemia was identified in eight of these (73%). Four patients in Group 1 were diagnosed with bowel ischemia, but treated palliatively because of their general condition. We compared the characteristics and outcomes of Groups 1 and 2 and identified possible prognostic factors for bowel ischemia. RESULTS: At admission, patients in Group 1 more commonly showed the peritoneal irritation sign, had lower base excess, higher lactate, and higher C-reactive protein, and more frequently had comorbid intestinal pneumatosis. Of the eight bowel ischemia surgery patients, four (50%) died, mainly because of anastomotic leak following bowel resection and primary anastomosis (3/4, 75%). All except one patient in Group 2, who presented with aspiration pneumonia, responded better to treatment. CONCLUSIONS: Earlier identification and grading of bowel ischemia according to the findings at admission should benefit patients with HPVG by reducing the incidence of unnecessary surgery and increasing the use of safer procedures, such as prophylactic stoma placement.

Extracorporeal Membrane Oxygenation in Transport Part 2: Complications and Troubleshooting.

Factors taken for granted while the extracorporeal membrane oxygenation (ECMO) patient is maintained in a hospital setting can become critical when planning for transport. These issues include but are not limited to positioning of patients on a small transport stretcher, positioning of cannulas and equipment, ensuring adequate power sources and supply, inefficient temperature control, and a much higher risk of decannulation. It is paramount to be comfortable with the management strategies required to handle common complications of ECMO with limited resources in a relatively austere environment. Coagulopathy and bleeding are the most common complications occurring in up to 50% of ECMO patients. Loss of flow and hypotension from loss of volume or profound vasodilation after ECMO initiation need to be managed accordingly. Oxygenator malfunction can occur, and clinicians must be able to recognize the indicators of this complication promptly. Loss of pulsatility, low end-tidal carbon dioxide (ETCO2), and differential hypoxia are common complications in venoarterial ECMO. In addition, an air embolism is life-threatening on venoarterial ECMO but may be better tolerated in the setting of venovenous ECMO. Recirculation in venovenous ECMO leads to circulation of poorly oxygenated blood and must be recognized and addressed. Lastly, pump failure, circuit rupture, and decannulation are devastating complications. Over the last decade, the use of extracorporeal membrane oxygenation (ECMO) has accelerated rapidly,1-3 providing support for patients in severe respiratory or cardiac failure. With ongoing clinical experience and improvements in technology, the indications for ECMO are increasing.4 Many areas are developing centralized ECMO centers to serve their surrounding communities.5-7 To use a centralized ECMO referral model, patients need access to effective, safe critical care transport, but transporting a patient on ECMO carries a significant risk of adverse events.8-13 The purpose of this review is to highlight some of the most common adverse events in ECMO transports and provide management suggestions. Note that these recommendations are not a substitution for close collaboration with medical control, and all adverse events should be promptly reported per organizational protocols.

Carbon Dioxide Embolism Associated With Transanal Total Mesorectal Excision Surgery: A Report From the International Registries.

BACKGROUND: Carbon dioxide embolus has been reported as a rare but clinically important risk associated with transanal total mesorectal excision surgery. To date, there exists limited data describing the incidence, risk factors, and management of carbon dioxide embolus in transanal total mesorectal excision. OBJECTIVE: This study aimed to obtain data from the transanal total mesorectal excision registries to identify trends and potential risk factors for carbon dioxide embolus specific to this surgical technique. DESIGN: Contributors to both the LOREC and OSTRiCh transanal total mesorectal excision registries were invited to report their incidence of carbon dioxide embolus. Case report forms were collected detailing the patient-specific and technical factors of each event. SETTINGS: The study was conducted at the collaborating centers from the international transanal total mesorectal excision registries. MAIN OUTCOME MEASURES: Characteristics and outcomes of patients with carbon dioxide embolus associated with transanal mesorectal excision were measured. RESULTS: Twenty-five cases were reported. The incidence of carbon dioxide embolus during transanal total mesorectal excision is estimated to be ≈0.4% (25/6375 cases). A fall in end tidal carbon dioxide was noted as the initial feature in 22 cases, with 13 (52%) developing signs of hemodynamic compromise. All of the events occurred in the transanal component of dissection, with mean (range) insufflation pressures of 15 mm Hg (12-20 mm Hg). Patients were predominantly (68%) in a Trendelenburg position, between 30° and 45°. Venous bleeding was reported in 20 cases at the time of carbon dioxide embolus, with periprostatic veins documented as the most common site (40%). After carbon dioxide embolus, 84% of cases were completed after hemodynamic stabilization. Two patients required cardiopulmonary resuscitation because of cardiovascular collapse. There were no deaths. LIMITATIONS: This is a retrospective study surveying reported outcomes by surgeons and anesthetists. CONCLUSIONS: Surgeons undertaking transanal total mesorectal excision must be aware of the possibility of carbon dioxide embolus and its potential risk factors, including venous bleeding (wrong plane surgery), high insufflation pressures, and patient positioning. Prompt recognition and management can limit the clinical impact of such events. See Video Abstract at http://links.lww.com/DCR/A961.

Bubble Formation in Children and Adolescents after Two Standardised Shallow Dives.

Circulating venous bubbles after dives are associated with symptoms of decompression sickness in adults. Up to now it is not known to what extent children and adolescents are subjected to a bubble formation during their shallow dives and if there are possible indications for that. The aim of this pilot study is to investigate whether bubbles and/or symptoms occur after standardised repeated dives performed by young divers. 28 children and adolescents (13.5±1.1 years) carried out two 25 min dives to a depth of 10 m with a 90 min surface interval. Before and after, echocardiographic data were recorded and evaluated with regard to circulating bubbles with an extended Eftedal-Brubakk-Scale by 2 different examiners. Bubbles were observed for a total of 6 subjects, Grade I (n=5) and Grade III (n=1). None of them showed any symptoms of decompression sickness. No differences were established regarding potential influencing factors on bubble formation between the groups with and without bubbles. The results indicate that even relatively shallow and short dives can generate venous bubbles in children and adolescents. To what extent this relates to the decompression sickness or clinical symptoms cannot be validated at this point.

The use of end-tidal argon to detect venous air embolism: foiled by "fake oxygen!"

Venous air-embolism (VAE) potentially catastrophic complication surgery. Based on previous data using changes in end-tidal nitrogen as an indicator of VAE, we surmised that changes in end-tidal argon (EtAr) may be an indicator of VAE. We sought to determine if a commercial mass-spectrometer (PCT Proline Analyzer 61700-8 Class 85, Ametek, Pittsburgh, PA 15238) could be used to detect changes in EtAr in an invitro model. A Drager Apollo™ (Drager, Lubeck, Germany) anesthesia machine was used to ventilate a dummy lung (2 L bag) with a minute ventilation of 6 L/min in 100% oxygen. The quadrupole mass-spectrometer (sampling at 0.0004 atm-cc/sec) was attached to the end-tidal inlet of the machine. Room air (1-60 mL) was injected into the dummy lung to simulate VAE. A strong baseline ion-current (1.2 × 10-12 amps) of argon was noted. Due to this contamination we were unable to detect "VAE" events of injected air. Argon represents approximately 0.93% of room air, or about 9300 parts per million (ppm). We detected about 2000 ppm argon in medical-grade oxygen (or 0.2%), limiting our ability to detect changes in EtAr. This is a USP-accepted contaminant, rendering this technology is insensitive for early, rapid detection of VAE. We assumed medical grade oxygen was pure and were surprised to learn otherwise. We want to share this likely largely unknown finding with the medical community.

Hyperbaric treatment of air or gas embolism: current recommendations.

Gas can enter arteries (arterial gas embolism, AGE) due to alveolar-capillary disruption (caused by pulmonary over-pressurization, e.g. breath-hold ascent by divers) or veins (venous gas embolism, VGE) as a result of tissue bubble formation due to decompression (diving, altitude exposure) or during certain surgical procedures where capillary hydrostatic pressure at the incision site is subatmospheric. Both AGE and VGE can be caused by iatrogenic gas injection. AGE usually produces stroke-like manifestations, such as impaired consciousness, confusion, seizures and focal neurological deficits. Small amounts of VGE are often tolerated due to filtration by pulmonary capillaries; however VGE can cause pulmonary edema, cardiac "vapor lock" and AGE due to transpulmonary passage or right-to-left shunt through a patient foramen ovale. Intravascular gas can cause arterial obstruction or endothelial damage and secondary vasospasm and capillary leak. Vascular gas is frequently not visible with radiographic imaging, which should not be used to exclude the diagnosis of AGE. Isolated VGE usually requires no treatment; AGE treatment is similar to decompression sickness (DCS), with first aid oxygen then hyperbaric oxygen. Although cerebral AGE (CAGE) often causes intracranial hypertension, animal studies have failed to demonstrate a benefit of induced hypocapnia. An evidence based review of adjunctive therapies is presented.

Recurrent facial nerve baroparesis in a military diver: a case report.

Middle ear barotrauma is common in diving. However, facial nerve baroparesis is a relatively rare complication. A dehiscent facial nerve canal may be a predisposing factor to developing this complication. Although there is an increasing number of facial baroparesis cases in the literature, they are likely still under-reported. In order to avoid unnecessary recompression treatments or detrimental effects to a professional diver's career, it is important to consider this in the differential diagnosis while evaluating dive injuries. This case report describes recurrent facial baroparesis in a military diver, which manifested on contralateral sides of his face. His initial presentation was misdiagnosed as an arterial gas embolism, which led to recompression treatment and a cardiac procedure. Upon recurrence about one year later, a complete work-up was done, which included an ENT evaluation and a CT scan. Imaging demonstrated a predisposing anatomic variant bilaterally. His symptoms resolved quickly and spontaneously both times, and he has been able to return to diving.

In-Hospital Mortality for Hepatic Portal Venous Gas: Analysis of 1590 Patients Using a Japanese National Inpatient Database.

BACKGROUND: Hepatic portal venous gas (HPVG) is rare but potentially serious condition. Main cause of HPVG is bowel ischemia, while detection of HPVG without bowel ischemia may have been increasing possibly due to widespread use of computed tomography. However, little is known about variation in etiologies of HPVG and mortality of HPVG with each etiology. We examined patient backgrounds, underlying diseases, and in-hospital mortality of HPVG patients using a national inpatient database. METHODS: Using the Diagnosis Procedure Combination database in Japan, we identified inpatients diagnosed with HPVG from July 1, 2010 to March 31, 2015. Patients' data included age, sex, comorbidities at admission, complications after admission, body mass index, surgical procedures, medications, and discharge status. In-hospital mortality was compared between the subgroups divided by the patient backgrounds and underlying diseases. RESULTS: A total of 1590 patients were identified during the study period. The mean age was 79.3 years old and the proportion of bowel ischemia was 53%. The overall in-hospital mortality was 27.3%. In-hospital mortality of HPVG with bowel ischemia, gastrointestinal tract (GIT) obstruction or dilation, GIT perforation, GIT infection, or sepsis was 26.8, 31.1, 33.3, 13.6, or 56.4%, respectively. Among patients with bowel ischemia, 32.2% patients received operation and their in-hospital mortality was 16.5%. CONCLUSIONS: HPVG patients in the present study were relatively older but less likely to die than those in previous studies. Attention should be paid to the fact that mortality of HPVG without bowel ischemia was not always lower compared to that with bowel ischemia.

Orbital Air Embolism After Intravenous Injection.

An asymptomatic air embolism in the right superior ophthalmic vein was discovered incidentally during a cerebral computed tomography, most likely due to a preceding intravenous fluid bolus. This case illustrates the potential risk of air emboli being propagated to the cerebral venous circulation during routine injections and fluid resuscitation.

Cardiac Air Embolism in Neonates: A Hemodynamic Perspective.

Cardiac air embolism should be suspected in any neonate with acute unexplained cardiovascular collapse or worsening oxygenation. We present here five cases that presented with the above symptoms. A comprehensive evaluation including targeted neonatal echocardiography and near-infrared spectroscopy helped confirm the diagnosis and assess the hemodynamic state. Management was supportive including left lateral positioning, chest compressions, and cardiovascular medications to treat pulmonary hypertension and systemic hypotension.

Hyperbaric oxygen therapy for cerebral air gas embolism following orthotopic heart transplant: case report.

Air gas embolism (AGE) is a rare complication of cardiac surgery, with high morbidity and mortality. We present a case of suspected AGE following orthotopic heart transplant. The patient received hyperbaric oxygen therapy with near-complete resolution of symptoms at follow-up. This case exemplifies the difficulty in diagnosis of AGE, the considerations involved in the treatment of a critical care patient in a hyperbaric chamber, and utility in treating a patient for AGE even after a delay in diagnosis.

Carbon Dioxide Flush of an Integrated Minimized Perfusion Circuit Prior to Priming Prevents Spontaneous Air Release Into the Arterial Line During Clinical Use.

Recently, an oxygenator with an integrated centrifugal blood pump (IP) was designed to minimize priming volume and to reduce blood foreign surface contact even further. The use of this oxygenator with or without integrated arterial filter was compared with a conventional oxygenator and nonintegrated centrifugal pump. To compare the air removal characteristics 60 patients undergoing coronary artery bypass grafting were alternately assigned into one of three groups to be perfused with a minimized extracorporeal circuit either with the conventional oxygenator, the oxygenator with IP, or the oxygenator with IP plus integrated arterial filter (IAF). Air entering and leaving the three devices was measured accurately with a bubble counter during cardiopulmonary bypass. No significant differences between all groups were detected, considering air entering the devices. Our major finding was that in both integrated devices groups incidental spontaneous release of air into the arterial line in approximately 40% of the patients was observed. Here, detectable bolus air (>500 µm) was shown in the arterial line, whereas in the minimal extracorporeal circulation circuit (MECC) group this phenomenon was not present. We decided to conduct an amendment of the initial design with METC-approval. Ten patients were assigned to be perfused with an oxygenator with IP and IAF. Importantly, the integrated perfusion systems used in these patients were flushed with carbon dioxide (CO2 ) prior to priming of the systems. In the group with CO2 flush no spontaneous air release was observed in all cases and this was significantly different from the initial study with the group with the integrated device and IAF. This suggests that air spilling may be caused by residual air in the integrated device. In conclusion, integration of a blood pump may cause spontaneous release of large air bubbles (>500 µm) into the arterial line, despite the presence of an integrated arterial filter. CO2 flushing of an integrated cardiopulmonary bypass system prior to priming may prevent spontaneous air release and is strongly recommended to secure patient safety.

Venous Air Embolism during Hysteroscopic Myomectomy: An Analysis of 7 Cases.

Venous air embolism (VAE) is a rare but potentially fatal complication of hysteroscopic myomectomy. The symptoms of VAE range from mild and clinically insignificant to complete cardiovascular collapse during surgery. Anesthesiologists and surgeons should be aware of the clinical characteristics and predisposing factors of this possible adverse event. This report analyzes 7 cases of VAE, which occurred at the University Hospitals Leuven, in patients undergoing hysteroscopic myomectomy from April 2009 to April 2011. Patient and myoma characteristics were compared to a control group of 27 patients who underwent uneventful hysteroscopic myomectomy during the same period of time. Analysis of baseline data including myoma size failed to identify predisposing factors. Clinical events in this series were classified according to their severity as minor (causing respiratory symptoms in 2 cases), moderate (accompanied by hemodynamic instability in 5 cases), or severe (requiring resuscitation in no cases). Case characteristics and therapeutic strategies in all cases were compared to reports from recent literature.

Cerebrospinal vascular diseases misdiagnosed as decompression illness: the importance of considering other neurological diagnoses.

The diagnosis of decompression illness (DCI), which is based on a history of decompression and clinical findings, can sometimes be confounded with other vascular events of the central nervous system. The authors report three cases of divers who were urgently transported to a hyperbaric facility for hyperbaric oxygen treatment of DCI which at admission turned out to be something else. The first case, a 45-year-old experienced diver with unconsciousness, was clinically diagnosed as having experienced subarachnoid hemorrhage, which was confirmed by CT scan. The second case, a 49-year-old fisherman with a hemiparesis which occurred during diving, was diagnosed as cerebral stroke, resulting in putaminal hemorrhage. The third case, a 54-year-old fisherman with sensory numbness, ataxic gait and urinary retention following sudden post-dive onset of upper back pain, was diagnosed as spinal epidural hematoma; he also showed blood collection in the spinal canal. Neurological insults following scuba diving can present clinically with confusing features of cerebral and/or spinal DCI. We emphasize the importance of considering cerebral and/or spinal vascular diseases as unusual causes of neurological deficits after or during diving.