A Case of Cerebral Air Embolism After Dental Procedure

Abstract

Air embolism is a rare and life-threatening event that occurs when air enters the cardiovascular system, usually secondary to iatrogenic vascular procedures. We present a 58-year-old woman who underwent a dental procedure (devitalization of a tooth) under local anesthesia, with a sudden onset of coma during manipulation and documentation of air in the vessels of the right frontal convexity sulci. After cerebral air embolism was confirmed, she received hyperbaric oxygen therapy, with resorption of the gas, but clinically she developed a super-refractory status epilepticus with a persistent coma. The slow clinical course required the exclusion of other etiologies of coma. The pathophysiology is not well known; however, it appears to be related to the injection of air by the high-speed dental drill through the soft tissue adjacent to the roots of the teeth, nearby the bloodstream. We highlight this event because of this unlikely association, which may delay diagnosis and the good results of hyperbaric medicine on prognosis.

Keywords: cerebral air embolism; coma; dental procedure; hyperbaric oxygen therapy; super-refractory status epilepticus.

Figure 1. Axial brain CT scan showing serpiginous hypodensity in the high right anterior frontal high convexity (blue arrow on A and B), compatible with air in the sulci, with no ischemic lesion objectified

Figure 2. Axial brain CT scan five hours after HBOT therapy showing reabsorption of air at the anterior frontal high convexity sulci (blue arrow on A and B)

Figure 3. Axial brain magnetic resonance imaging, the first 24 hours after the event, showing on DWI a gyroscopic hypersignal in multiple cortical areas on the right frontal high convexity, consistent with a predominant cortical ischemic lesion (double blue arrow on A), still without translation on FLAIR (B) as expected in these lesions with a short time of onset