INTERVENTIONAL NEURORADIOLOGY Severe pulmonary oedema following therapeutic embolization with Onyx for cerebral arteriovenous malformation C. Murugesan & Sundararaj Saravanan & John Rajkumar & Jagadish Prasad & Sanjay Banakal & Kanchi Muralidhar Received: 19 September 2007 / Accepted: 27 November 2007 / Published online: 3 January 2008 # Springer-Verlag 2007 Abstract Acute respiratory distress syndrome (ARDS) is characterized by sudden onset of respiratory distress, infiltrates on radiographs consistent with pulmonary oede- ma, hypoxaemia and increased work in breathing. Infiltrates on radiographs are bilateral, but may be patchy or diffuse and fluffy or dense. It is associated with absence of left heart failure and a PaO 2 /FiO 2 ratio of ≤200. Ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide (DMSO), which was approved by the US FDA in July 2005, is used as an embolic agent for cerebral arteriovenous malformation (AVM). It is a biocompatible liquid polymer that precipitates and solidifies on contact with blood, thus forming a soft and spongy embolus. We report a case of ARDS following therapeutic embolization with ethylene vinyl alcohol copolymer for cerebral AVM under general anaesthesia. Experienced perioperative physicians adopted standard anaesthetic technique and monitoring for this procedure. Acute respiratory distress and hypoxaemia developed in the patient following extubation of the trachea. Infiltrates seen on postprocedural chest radiographs were consistent with pulmonary oedema. DMSO, the solvent for the ethylene vinyl alcohol copolymer, is excreted via the lungs after administration and we postulate that DMSO was the possible cause of ARDS in this patient. Monitoring of haemodynamic parameters (invasive blood pressure, electrocardiography) and ventilatory parameters (ETCO 2 , SpO 2 , airway pressure monitoring) are important in the recognition of this possible event. One should be vigilant and anticipate this complication following thera- peutic embolization with ethylene vinyl alcohol polymer for the treatment of cerebral AVM. Keywords Pulmonary oedema . Ethylene vinyl alcohol copolymer . Arteriovenous malformation . Dimethyl sulfoxide . Negative pressure pulmonary oedema Introduction Therapeutic embolization is one of the strategies for the treatment of cerebral arteriovenous malformation (AVM), in addition to microneurosurgery and stereotactic radiosurgery [1]. In some patients it may lead to a total and permanent cure, but in most patients it will be an adjunctive therapy to radiosurgery [2]. Ethylene vinyl alcohol (EVAL) copolymer dissolved in dimethyl sulfoxide (DMSO), which was approved by the US FDA in July 2005, is used as an embolic agent for the treatment of cerebral AVM [3]. It is a biocompatible liquid polymer that precipitates and solidifies on contact with blood, thus forming a soft and spongy embolus [4]. Case report A 32-year-old male patient presented with complaints of severe headache of 4 months duration and one episode of loss of consciousness 3 months previously. He was evaluated and diagnosed as having a right temporal AVM (Fig. 1). Systemic examination including neurological examination was normal. Haematological investigations Neuroradiology (2008) 50:439–442 DOI 10.1007/s00234-007-0348-4 C. Murugesan (*) : S. Saravanan : J. Rajkumar : J. Prasad : S. Banakal : K. Muralidhar Narayana Hrudayalaya Institute of Medical Sciences, No.258/A, Bommasandra Industrial Area, Anekal Taluk, Bangalore 560099, India e-mail: murugesanhosur@gmail.com