1512 - Deep Dive Disaster: A Case Report on Decompression Sickness

Case Diagnosis: Disorder of Consciousness (DoC) secondary to Decompression Illness (DCI)



Case Description: 53-year-old female without past medical history presented to our facility in a minimally conscious state, with inconsistent command follow and spastic quadriparesis due to decompression sickness and subsequent air embolisms following scuba diving. Imaging notable for multiple subcortical lesions in the cerebellar/cerebral hemispheres with mesencephalic infarction, findings suggestive of anoxic brain injury due to arterial gas embolism. Initial hospitalization was complicated by sepsis, ventricular tachycardia, cardiac arrest, and PEG placement. Rehabilitation course was complicated by seizures initially treated with Keppra, later cross-titrated to Depakote due to emotional lability. She emerged from a disorder of consciousness and was discharged at a level of substantial assistance for eating, showering, and upper body dressing, in addition to being able to walk 50 feet with moderate assistance with an EVA walker.

Discussions: Diving increases the propensity of developing nitrogen bubbles, leading to nervous system damage by inducing a systemic inflammatory response. These bubbles can pass from venous to arterial circulation by either pulmonary barotrauma, patent foramen ovale, or diffusion of nitrogen bubbles into the bloodstream and cause neurological symptoms of varying severity. Cerebral decompression sickness accounts for 30-40% of cases with symptoms depending on emboli location, despite a predilection for anterior circulation. Although cases of anterior cerebral artery dissection in scuba divers have been documented, to our knowledge, no cases of DoC secondary to DCI have been reported. Comprehensive and intensive inpatient rehabilitation allowed our patient to make significant gains in cognition and physical functioning similar to those with DoC secondary to more common types of brain injuries.

Conclusions: Our report highlights a rare case of DCI-related DoC and emphasizes the importance of a comprehensive and intensive inpatient rehabilitation program to help patients who have sustained DoC from rare etiologies achieve emergence and improved functional outcomes.