A 53 year-old right-handed Caucasian male with colon polyps presented to the emergency department with acute vision loss. On examination, patient was found to have a left homonymous superior quadrantanopia. While discussing risks and benefits of IV tPA, patient revealed that he had undergone a colonoscopy with polypectomy the day prior. Decision was made to proceed with IV tPA.
Forty-minutes after the initial tPA bolus, patient became confused, hypoxic, and hypotensive. tPA infusion was stopped, and he was placed on supplemental oxygen. No evidence of hemorrhage was seen on CT, but a hypodense pocket was noted in the right ventricle (RV) of the heart. Subsequent imaging confirmed the presence of a large air embolus in patient’s RV and proximal pulmonary arteries. He was immediately started on 100% FiO2 and placed in left lateral, Trendelenburg position. Two possible causes of VAE were identified. First, patient had undergone a colonoscopy one day before his presentation, and insufflation of gases into the abdomen has been well-documented to cause VAEs in anesthesiology literature. Second, a CTA of the head and neck was completed in the ED, and pressure injection of contrast media has also been implicated in rare cases of VAE. Although patient decompensated after receiving bolus of IV tPA, we do not have any reasons to believe that the bolus itself caused his VAE.