A 77-year-old male patient with a smoking history of 55 pack-years was referred to our hospital with an abnormality on the chest X-ray detected during his annual medical checkup (Figure 1).
Contrast-enhanced CT revealed a cavitary mass measuring 50 mm in diameter in the right lower lobe, a mass measuring 34 mm in diameter in the left lower lobe, and an enlarged left hilar lymph node (#11) (Figure 1). No metastatic lesions were detected. Based on these findings, the patient was strongly suspected as having a double primary lung cancer.
At the first admission, flexible fiberoptic bronchoscopy was performed, and the cytological findings in endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) specimens obtained from the left hilar lymph node were classified as class V, squamous cell carcinoma. After the examination, slight left pneumothorax was noted, which improved spontaneously without additional treatment.
At the second admission, flexible fiberoptic bronchoscopy was performed again under conscious sedation achieved by intravenous injection of 1.5 mg of midazolam. The patient was placed in the left lateral position and the cytological findings in the specimens obtained by curettage and instillation of saline into the right B6a were classified as class III. The patient had a little bleeding and coughing during the examination. After the examination, 0.2 mg of flumazenil was injected intravenously; however, the patient remained drowsy. Other vital signs were normal. When he became more alert three hours after the examination, he was found to have slurred speech, left hemiplegia, and left spatial neglect. The National Institute of Health Stroke Scale (NIHSS) score was 21. Emergency head CT revealed obscuring of the corticomedullary junction in the brain region supplied by the right middle cerebral artery (MCA) (Figure 2), and cerebral infarction was suspected. Reconstruction of the CT images using the mediastinal window settings revealed scattered air bubbles in the MCA region, based on which the patient was definitively diagnosed as having developed CAAE (Figure 2). Instead of hyperbaric oxygen (HBO2) therapy, which was not available at our hospital, we administered normobaric oxygen (NBO2) therapy (10 L/min of oxygen delivered via a nonrebreathing mask). The following day, the patient received fosphenytoin and levetiracetam for clonic convulsion extending from his left face to the upper arm. A repeat head CT showed disappearance of the air bubbles but emergence of cerebral edema, which improved over the following six days. While the patient was eventually able to walk using a four-legged cane, paresis of the left upper arm and left spatial neglect remained, and the Eastern Cooperative Oncology Group (ECOG) performance status was estimated to be 3. We therefore discontinued any further investigation or treatment of the lung cancer. Approximately four months after the second admission, the patient was transferred to a hospice near his hometown.