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Neuroimaging Features of Cerebral Air Embolism: A Matched Case-Control Study
Natalie L Ullman1, Yu Sakai2, Moira Flanigan3
1From the Division of Vascular Neurology (N.L.U., P.B., S.R.M., B.L.C.), University of Pennsylvania, Philadelphia, Pennsylvania Natalie.ullman@pennmedicine.upenn.edu.
Insights
Cerebral air embolism (CAE) causes unique MRI patterns, including gyriform infarction and borderzone involvement, distinguishing it from atrial fibrillation (AF) stroke. Identifying these features aids in timely diagnosis of this critical condition.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- Cerebral air embolism (CAE) is a rare but treatable cause of ischemic stroke.
- Distinguishing CAE from other stroke types, like those from atrial fibrillation (AF), is clinically challenging but crucial for effective treatment.
- Accurate diagnosis of CAE is critical for initiating appropriate and timely interventions.
Purpose of the Study:
- To define the characteristic neuroimaging features of cerebral air embolism (CAE) on MRI.
- To compare MRI findings in patients with CAE to those with cardioembolic stroke due to atrial fibrillation (AF).
- To identify imaging markers that can help differentiate CAE from AF-related stroke.
Main Methods:
- A retrospective, matched case-control study was conducted.
- CAE cases (2012-2023) were matched 1:2 with control patients experiencing stroke due to AF, excluding those treated with thrombolytics or thrombectomy.
- A neuroradiologist, blinded to group allocation, reviewed all MRIs to identify pre-specified neuroimaging features.
Main Results:
- Gyriform infarction patterns were predominant in CAE (86%) compared to AF stroke (11%) (p<0.001).
- CAE patients more frequently presented with multiple (93% vs. 50%) and bilateral (79% vs. 43%) infarctions.
- Cortical borderzone involvement was significantly more common in CAE (86%) than in AF stroke (25%) (p<0.001).
Conclusions:
- Cerebral air embolism (CAE) exhibits characteristic gyriform infarction patterns on MRI, differentiating it from typical cardioembolic stroke.
- The constellation of gyriform infarction, cortical borderzone predilection, and multifocal infarctions strongly suggests CAE.
- Timely identification of CAE, facilitated by recognizing these distinct imaging findings, is critical for managing this uncommon but serious condition.
Background And Purpose:
Cerebral air embolism (CAE) is a rare but treatable cause of ischemic stroke. Clinically, CAE may be difficult to distinguish from stroke due to more typical thromboembolic causes, but accurate diagnosis is critical to initiate appropriate treatment. We aimed to define the imaging features of CAE by comparing MRI from patients with confirmed CAE with those in cardioembolic stroke due to atrial fibrillation (AF).
Materials And Methods:
In a retrospective, matched case-control study, CAE cases from 2012-2023 were matched 1:2 by presenting National Institutes of Health Stroke Scale (NIHSS) to control patients who had stroke due to AF and were not treated with thrombolytics or thrombectomy. MRIs were reviewed by a neuroradiologist blinded to group. The primary outcome was the presence of prespecified neuroimaging features on MRI.
Results:
Fourteen patients with stroke due to CAE (median age 61, 64% women, median NIHSS 12) and 28 controls with stroke due to AF (median age 81, 43% women, median NIHSS 12) were included. The predominant infarction topography in patients with CAE was gyriform in 86%, punctate in 7%, and wedge-shaped in 7%, whereas in patients with stroke due to AF, the predominant infarction topography was wedge-shaped in 71%, punctate in 18%, and gyriform in 11% (P < .001). Patients with CAE more often presented with multiple (93% versus 50%, P = .007) and bilateral infarctions (79% versus 43%, P = .05). Cortical borderzone involvement was more frequent in patients with CAE compared with those with AF (86% versus 25%, P < .001). The presence of both predominantly gyriform infarction topography and cortical borderzone involvement had a 76.6% sensitivity and 96.4% specificity for CAE.
Conclusions:
CAE causes characteristic gyriform infarction patterns on MRI that are distinct from typical cardioembolic stroke. In addition, cortical borderzone predilection and multifocal infarctions were substantially more frequent in CAE. This constellation of findings, in the appropriate clinical context, should strongly suggest CAE as the mechanism of neurologic injury and may facilitate the timely identification of this uncommon but critical diagnosis.
