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NEUROLOGY 2009;72:e54-e55
© 2009 American Academy of Neurology
Resident and Fellow Section

Teaching NeuroImages: Cerebral air embolism secondary to atrial-esophageal fistula

T. L. Williams, MD, D. R. Parikh, MD, J. R. Hopkin, MD, T. G. Lukovits, MD, A. T. Kono, MD, A. C. Mamourian, MD and B. T. Harris, MD, PhD

From Dartmouth-Hitchcock Medical Center, Lebanon, NH.

Address correspondence and reprint requests to Dr Harris, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756 bharris{at}dartmouth.edu

A 58-year-old man presented in minimally arousable state hours after experiencing right-sided paresthesias. He had a distant history of esophageal carcinoma, treated by esophagogastrectomy, local radiotherapy, and dilations. He was admitted, and the consensus diagnosis was probable infective endocarditis with embolic cerebral infarctions. He was treated with antibiotics but continued to have multifocal infarctions over several weeks and died. At autopsy, an atrial-esophageal fistula tract (figure) was identified without recurrent carcinoma. Air, food, and bacteria were introduced through this fistula to the circulation, resulting in sepsis and embolization to the brain with multifocal infarctions. The brain was diffusely edematous with multiple, variably sized hemorrhagic infarctions and smooth spaces from air emboli. Histopathology showed subacute infarctions predominated by macrophages within rarefied neuroglial tissue and no organisms on special stains.


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  		Figure Premortem and autopsy images

(A) Axial noncontrast CT (1), diffusion-weighted (2), and gadolinium-enhsanced T1 (3) images demonstrate areas of decreased attenuation consistent with intraparenchymal air pockets (1) and areas of increased signal by MRI suggesting acute infarcts (2, 3). (B) Postmortem cerebrum with diffuse edema, smooth cavitary lesions (1), and subacute hemorrhagic infarctions (2, 3). (C) Heart displays probe-patent opening in left atria, en bloc cross-section of the atrial-esophageal fistula (insert). (D) Histologic section of premortem biopsy displaying subacute infarct with macrophages and vascular proliferation (bar = 100 µm).

 

*These authors contributed equally as first authors.

Disclosure: The authors report no disclosures.





This Article
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Right arrow Articles by Williams, T. L.
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PubMed
Right arrow PubMed Citation
Right arrow Articles by Williams, T. L.
Right arrow Articles by Harris, B. T.
Related Collections
Right arrow Gastrointestinal
Right arrow All Cerebrovascular disease/Stroke
Right arrow Cardiac; see Cerebrovascular Disease/Cardiac
Right arrow Embolism
Right arrow Infarction

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