Diffuse Bi-hemispheric Cortical Infarction Secondary to Cerebral Air Embolism After Elective Esophagogastroduodenoscopy: A Case Report and Review of Literature.

Cerebral air embolism (CAE) is a rare entity and is more often secondary to iatrogenic causes. We present a rare case of CAE post esophagogastroduodenoscopy (EGD) with a shower of emboli resulting in diffuse cortical infarction. An 80-year-old man with gastroesophageal reflux disease underwent an elective EGD for esophageal dilatation. During the procedure, there was significant arterial and venous bleeding which subsided with treatment. After the procedure, the patient became comatose with the decerebrate extensor posturing to painful stimulation. Computed tomography without contrast revealed multiple foci of CAE. Diffusion-weighted magnetic resonance images performed at the same time showed numerous areas of acute ischemic lesions affecting primarily the Gray Matter, demonstrating both cortical micro air emboli and bi-hemispheric, global hypoperfusion leading to cortical ribboning pattern.  There have been less than 22 cases of CAE after EGD in the literature, most of which were middle cerebral arterial territory infarctions. Our clinical images represent one of the extremely rare cases showing a shower of emboli and global hypoperfusion-induced gray matter infarction due to CAE-causing brain herniation.