Devastating cerebral Lipiodol® embolization related to therapeutic lymphangiography for refractory chylothorax in a patient with Behçet's disease.

Onset of neurological symptoms early after intranodal lymphangiography can occur due to Lipiodol droplet migration through intrapulmonary lymphovenous communication. Patients with Behçet's disease may be at higher risk of developing this devastating complication.

Hyperbaric oxygen therapy for the prevention of arterial gas embolism in food grade hydrogen peroxide ingestion.

Food grade hydrogen peroxide ingestion is a relatively rare presentation to the emergency department. There are no defined guidelines at this time regarding the treatment of such exposures, and providers may not be familiar with the potential complications associated with high concentration hydrogen peroxide ingestions. In this case series, we describe four patients who consumed 35% hydrogen peroxide, presented to the emergency department, and were treated with hyperbaric oxygen therapy. Two of the four patients were critically ill requiring intubation. All four patients had evidence on CT or ultrasound of venous gas emboli and intubated patients were treated as if they had an arterial gas embolism since an exam could not be followed. After hyperbaric oxygen therapy each patient was discharged from the hospital neurologically intact with no other associated organ injuries related to vascular gas emboli. Hyperbaric oxygen therapy is an effective treatment for patients with vascular gas emboli after high concentration hydrogen peroxide ingestion. It is the treatment of choice for any impending, suspected, or diagnosed arterial gas embolism. Further research is needed to determine which patients with portal venous gas emboli should be treated with hyperbaric oxygen therapy.

Cerebral Lipiodol Embolism after Lymphatic Embolization for Plastic Bronchitis.

An adolescent with plastic bronchitis due to congenital heart disease had altered mental status after an interventional lymphatic procedure in which lipiodol contrast was used. Neuroimaging revealed cerebral lipiodol embolization due to direct shunting between lymphatic channels and pulmonary veins. Cerebral lipiodol embolization is a potential neurologic morbidity associated with interventional lymphatic procedures.

Cerebral arterial gas embolism after pre-flight ingestion of hydrogen peroxide.

Cerebral arterial gas embolism (CAGE) is a feared complication of ambient depressurisation and can also be a complication of hydrogen peroxide ingestion. We present an unusual case of CAGE in a 57-year-old woman exposed to both of these risk factors. We describe her subsequent successful treatment with hyperbaric oxygen, despite a 72-hour delay in initial presentation and diagnosis, and discuss the safety of aero-medical transfer following hydrogen peroxide ingestions.

Cerebral lipiodol embolism after transarterial chemoembolization for hepatic carcinoma: a case report.

We report a case of cerebral lipiodol embolism (CLE) after transarterial chemoembolization (TACE) for unresectable hepatic carcinoma (HCC). A 54-year-old man with unresectable HCC underwent TACE via the right hepatic artery and right inferior phrenic artery using a mixture of 40 mg pirarubicin and 30 mL lipiodol. His level of consciousness deteriorated after TACE, and non-contrast computed tomography revealed a CLE. The cerebral conditions improved after supportive therapy. The complication might have been due to hepatic arterio-pulmonary vein shunt caused by direct invasion of the tumor. Even though CLE is an uncommon complication of TACE, we should be aware of these rare complications in patients with high risk factors.

Cerebral lipiodol embolism proven by dual-energy computed tomography: a case report.

We report a case of cerebral lipiodol embolism after transarterial chemoembolization of hepatocellular carcinoma, which was confirmed by dual-energy computed tomography (CT). A 44-year-old male patient developed left leg weakness after transarterial chemoembolization for hepatocellular carcinoma. The noncontrast CT scan of his brain revealed multiple high-attenuating lesions scattered along the gyral surface of the both cerebral hemispheres; meanwhile, the lesions disappeared on the iodine-removed virtual noncontrast images generated from dual-energy CT.

Cerebral lipiodol embolism following transcatheter arterial chemoembolization for hepatocellular carcinoma.

Cerebral lipiodol embolism (CLE) is an extremely rare complication of transcatheter arterial chemoembolization for hepatocellular carcinoma (HCC). The authors present a case of CLE that occurred after the second hepatic arterial chemoembolization for HCC, and attempt to introduce several plausible mechanisms of CLE, after reporting the clinical and radiological findings and reviewing the medical literature.

Cerebral embolism of iodized oil (lipiodol) after transcatheter arterial chemoembolization for hepatocellular carcinoma.

Cerebral lipiodol embolism is a rare complication of transcatheter arterial chemoembolization (TACE). Its pathological mechanism remains ambiguous despite several investigations. In Case 1, a 67-year-old man with hepatocellular carcinoma (HCC) experienced neurological deficits soon after undergoing a fourth session of TACE. Computed tomography (CT) scan showed multiple hyperdense lesions along the gyrus of frontal lobes and in the subcortical white matter. Transcranial Doppler (TCD) and transesophageal echocardiogram performed during the intravenous injection of agitated saline documented the presence of a right-to-left shunt (RLS) by demonstrating microbubbles in the left middle cerebral artery and left atrium. In Case 2, a 63-year-old woman underwent a third TACE due to a large HCC. After the procedure, her mental status deteriorated. Brain CT showed multiple hyperdense lesions on the cerebral and cerebellar cortex. TCD with agitated saline showed multiple microembolic signals shortly after the injection of agitated saline. The risk of cerebral lipiodol embolism may increase with recurrence and progression of HCC in patients who have a pre-existing RLS in the heart or lung. A test for the detection of an RLS may be necessary to identify patients with a heightened risk of cerebral embolism when multiple TACE procedures are required. TACE for HCC can cause pulmonary embolism or infarction.(1,2) However, cerebral lipiodol embolism is rare after TACE. There have been several reports of cerebral embolism after TACE, but their exact mechanism has not yet been fully elucidated. We report herein 2 patients who developed cerebral lipiodol embolism after undergoing multiple TACE procedures for remnant HCC through a pre-existing RLS.

Cerebral air gas embolism from concentrated hydrogen peroxide ingestion.

INTRODUCTION: Ingestion of a small amount of concentrated hydrogen peroxide can cause cerebral air gas embolism (CAGE). Hyperbaric oxygen therapy (HBOT) is the standard of care in the treatment of CAGE. We report a case of CAGE after accidental ingestion of 33%hydrogen peroxide treated with HBOT resulting in reversal of both the clinical and radiologic abnormalities. CASE REPORT: A 48 year-old male took two sips of 33% hydrogen peroxide. A short time later, he developed hematemesis, left sided hemiplegia, confusion, and left homonymous hemianopsia. Initial laboratory studies, chest x-ray, and brain CT were normal. MRI demonstrated areas of restricted diffusion and T2 hyper intensities in multiple vascular territories consistent with ischemia due to CAGE. Eighteen hours after arrival, the patient underwent HBOT at 3 atmospheres absolute (ATA) for 30 minutes and 2.5 ATA for 60 minutes with clinical improvement. Follow-up MRI at six months demonstrated resolution of the hyper intensities. DISCUSSION: A search of MEDLINE from 1950 to present revealed only two cases of CAGE from ingestion of concentrated hydrogen peroxide treated with HBOT. Both cases, similar to ours, had complete resolution of symptoms. Of the seven reported cases of CAGE from hydrogen peroxide that did not undergo HBOT, only in one patient was there a report of symptom resolution. CONCLUSION: Ingestion of even a small amount of concentrated hydrogen peroxide can result in cerebral air gas embolism. Hyperbaric oxygen therapy may be of benefit in reversing the symptoms and preventing permanent neurological impairment.

[Acute intoxication with hydrogen peroxide with air emboli in central nervous system--a case report]. / Ostre zatrucie nadtlenkiem wodoru powiklane zatorami powietrznymi osrodkowego ukladu nerwowego--opis przypadku.

UNLABELLED: 54-year-old woman with brain gas emboli after an accidental ingestion of concentrated hydrogen peroxide was described. Hydrogen peroxide (H2O2) is a water-soluble, caustic liquid. Exposure to concentrated (> 30-35%) hydrogen peroxide may cause cardiorespiratory insufficiency, shock, convulsions, coma, and chemical burns of skin and mucous membranes. Arterial gas embolization in central nervous system is a relatively rare complication. There are three possible mechanisms of gas embolization: persisting patent foramen ovale, pulmonary gas emboli caused by aspiration of hydrogen peroxide to the lower respiratory tract, formation of gas emboli after reaching the brain. Absence of gas emboli and cerebral infarction in CT does not exclude intoxication. Hyperbaric therapy is most effective for brain air embolism complicating hydrogen peroxide poisoning in acute phase. Some authors suggested that this therapy is also effective if administered during the subacute phase. CONCLUSIONS: Neurologic symptoms after ingestion of hydrogen peroxide may suggest gas embolism of the cerebral vasculature. The absence of atrial septal defect does not exclude the possibility of cerebral air embolism. The absence of gas and cerebral infarction in CT scans does not exclude brain gas embolism. The use of hyperbaric therapy should be considered in treating severe cases of hydrogen peroxide poisoning.

Cerebral lipiodol embolism: a complication of transcatheter arterial chemoembolization for hepatocellular carcinoma.

We report a case of cerebral lipiodol embolism following transcatheter chemoembolization (TACE) for hepatocellular carcinoma. A 70-year-old woman with a large unresectable hepatocellular carcinoma underwent TACE. Her level of consciousness deteriorated after the procedure, and magnetic resonance imaging and non-contrast computed tomography revealed a cerebral lipiodol embolism. Despite intensive care, the patient died 2 weeks later. The complication might have been due to systemic-pulmonary shunts caused by previous surgeries and/or direct invasion of the recurrent tumor.

Cerebral lipiodol embolism after transcatheter arterial chemoembolization of hepatocellular carcinoma.

A case of cerebral lipiodol embolism after transcatheter arterial chemoembolization (TACE) of hepatocellular carcinoma is presented. A 76-year-old man underwent TACE for advanced hepatocellular carcinoma. Immediately after chemoembolization, his level of consciousness deteriorated. Computed tomography revealed deposition of iodized oil in the cerebral cortex, basal ganglia, and thalami. Magnetic resonance imaging showed restricted diffusion within the thalami and basal ganglia. The patient's level of consciousness gradually improved, and all neurologic symptoms disappeared over 6 weeks.

Cerebral lipiodol embolism during transcatheter arterial chemoembolization.

Cerebral lipiodol embolism (CLE) is a rare complication that may occur during chemoembolization. The authors present three cases of CLE during transcatheter arterial chemoembolization for hepatocellular carcinoma. Multiple small nonconfluent hyperintense intracerebral lesions were found on the diffusion-weighted and fluid-attenuated inversion recovery MRI. Clinical signs completely resolved and MRI lesions markedly improved on follow-up evaluation within a 3-week period.

Resolution of delayed altered mental status associated with hydrogen peroxide ingestion following hyperbaric oxygen therapy.

CASE REPORT: An 82-year-old women presented with altered mental status, seizure, and apnea after an accidental ingestion of concentrated hydrogen peroxide. Ingestion of concentrated peroxide can result in gas embolism of the cerebral vasculature. After hyperbaric treatment, the patient had prompt and full neurologic recovery. To the best of the authors' knowledge, this is the first reported case of reversal of significant altered mental status associated with hydrogen peroxide ingestion in temporal relation with hyperbaric oxygen therapy. Emergency physicians need to be aware of the dangers of peroxide ingestion and may wish to consider hyperbaric oxygen as a potential additional treatment for severe cases.