Fatal Cerebral Air Embolism Due to a Patent Foramen Ovale during Endoscopic Retrograde Cholangiopancreatography

Fatal air embolism to the cerebrum during an endoscopic retrograde cholangiopancreatography (ERCP) has not been reported in a patientwith a biliodigestive anastomosis and multiresistant extended-spectrum β-lactamase Escherichia coli (ESBL) bacteremia. A 59-yearoldwoman with a history of laparoscopic cholecystectomy and iatrogenic injury of the right choledochal duct, choledochojejunostomy(biliodigestive anastomosis), recurrent cholangitis, revision of the biliodigestive anastomosis, recurrent liver abscesses, and recurrentstenting of stenotic bile ducts, was admitted because of fever and tenderness of the right upper quadrant. On ERCP, a previously deployedcovered Wallstent was replaced. Blood cultures grew ESBL. After stent removal 8 days later, the patient did not wake up and developedarterial hypotension and respiratory insufficiency, requiring mechanical ventilation. Computed tomography scans showed extensiveair embolism to the liver, heart, and cerebrum. She died 1 day later. Although the exact pathogenesis of the fatal cerebral air embolism remainsspeculative, the nonphysiological anatomy and chronic infection with ESBL may have been contributory factors.