{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T01:34:32Z","timestamp":1790040872686,"version":"4.0.1"},"reference-count":20,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T00:00:00Z","timestamp":1779062400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Endoscopic injection of N-butyl-2-cyanoacrylate (Histoacryl) is a first-line treatment for bleeding gastric varices. Although generally safe, rare systemic complications including paradoxical cerebral embolization can occur, carrying devastating neurological consequences.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case presentation<\/jats:title>\n                    <jats:p>We report a 62-year-old man with probable alcohol-related cirrhosis who presented with acute upper gastrointestinal bleeding secondary to gastroesophageal gastric varices and underwent urgent endoscopic cyanoacrylate injection with a total volume of 8\u202fmL, achieving immediate hemostasis. Post-procedure, the patient failed to regain consciousness. Neuroimaging revealed extensive multifocal cerebral embolization with radiopaque glue material involving both anterior and posterior circulation territories, consistent with systemic cyanoacrylate embolization. Transesophageal echocardiography with agitated saline contrast confirmed the absence of a patent foramen ovale or intracardiac right-to-left shunt, supporting an extracardiac mechanism of embolization, most probably via portopulmonary venous anastomoses related to portal hypertension. Despite intensive neurocritical care, the patient developed progressive cerebral edema with herniation and died 48\u202fh later.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Cerebral embolization is a rare but catastrophic complication of endoscopic cyanoacrylate injection. This case highlights the role of unrecognized portosystemic collateral pathways in facilitating paradoxical embolization even in the absence of a cardiac shunt. Failure to awaken or acute neurological deterioration post-variceal therapy should prompt immediate neuroimaging. Greater emphasis on pre-procedural imaging, careful injection technique, and risk-reduction strategies is essential.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fmed.2026.1825258","type":"journal-article","created":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T15:12:46Z","timestamp":1779117166000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Case Report: Multifocal cerebral infarctions caused by cyanoacrylate glue embolization after gastric variceal injection"],"prefix":"10.3389","volume":"13","author":[{"given":"Ahmed Hafez","family":"Mousa","sequence":"first","affiliation":[{"name":"Neurosciences, Dubai Health","place":["Dubai, United Arab Emirates"]},{"name":"Department of Neurosurgery, Graduate Medical Education, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai Health","place":["Dubai, United Arab Emirates"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samar Iltaf","family":"Mairajuddin","sequence":"additional","affiliation":[{"name":"Neurosciences, Dubai Health","place":["Dubai, United Arab Emirates"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anas","family":"Alnajjar","sequence":"additional","affiliation":[{"name":"Department of Radiology, Graduate Medical Education, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai Health","place":["Dubai, United Arab Emirates"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ahmed","family":"Aramram","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Dubai Health","place":["Dubai, United Arab Emirates"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdullah","family":"AlKurdi","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Dubai Health","place":["Dubai, United Arab Emirates"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Youssef","family":"ElSabban","sequence":"additional","affiliation":[{"name":"College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai Health","place":["Dubai, United Arab Emirates"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Doaa Zain","family":"Fadaaq","sequence":"additional","affiliation":[{"name":"College of Medicine and Surgery, Batterjee Medical College","place":["Jeddah, Saudi Arabia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ayoub Ahmed","family":"Abedzadeh","sequence":"additional","affiliation":[{"name":"Department of Radiology, Graduate Medical Education, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai Health","place":["Dubai, United Arab Emirates"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shaikh Sayeed","family":"Iqbal","sequence":"additional","affiliation":[{"name":"Department of Radiology, Graduate Medical Education, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai Health","place":["Dubai, United Arab Emirates"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abubaker Abdul Rahman Shaffi","family":"Al Madani","sequence":"additional","affiliation":[{"name":"Neurosciences, Dubai Health","place":["Dubai, United Arab Emirates"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Babacar","family":"Cisse","sequence":"additional","affiliation":[{"name":"Neurosciences, Dubai Health","place":["Dubai, United Arab Emirates"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,5,18]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"1098","DOI":"10.1016\/j.cgh.2021.01.027","article-title":"AGA clinical practice update on management of bleeding gastric varices: expert review","volume":"19","author":"Henry","year":"2021","journal-title":"Clin Gastroenterol Hepatol"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"1180","DOI":"10.1097\/HEP.0000000000000647","article-title":"AASLD practice guidance on portal hypertension and varices in cirrhosis","volume":"79","author":"Kaplan","year":"2024","journal-title":"Hepatology"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"4510213","DOI":"10.1155\/crcc\/4510213","article-title":"Endoscopic variceal therapy with multisystemic glue embolism: a case report and narrative review of a rare but severe complication","volume":"2025","author":"Penati","year":"2025","journal-title":"Case Rep Crit Care"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"817","DOI":"10.1007\/s11739-018-1892-0","article-title":"Cerebral infarction following cyanoacrylate endoscopic therapy of duodenal varices in a patient with patent foramen ovale","volume":"13","author":"Abbar","year":"2018","journal-title":"Intern Emerg Med"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"2021","DOI":"10.1007\/s11739-021-02692-1","article-title":"Cerebral infarction following cyanoacrylate therapy of duodenal varices: comment","volume":"16","author":"Talerico","year":"2021","journal-title":"Intern Emerg Med"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"504","DOI":"10.1007\/s12072-009-9130-5","article-title":"Cerebral embolism following N-butyl-2-cyanoacrylate injection for esophageal post-banding ulcer bleed","volume":"3","author":"Abdullah","year":"2009","journal-title":"Hepatol Int"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"1554","DOI":"10.1007\/s12070-023-04357-1","article-title":"Endovascular embolization of traumatic vessel injury using N-butyl cyanoacrylate: a case series","volume":"76","author":"Morsi","year":"2024","journal-title":"Indian J Otolaryngol Head Neck Surg"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"2081","DOI":"10.1097\/00029330-200712010-00004","article-title":"Treatment of gastric varices by endoscopic sclerotherapy using butyl cyanoacrylate: 10 years\u2019 experience of 635 cases","volume":"120","author":"Cheng","year":"2007","journal-title":"Chin Med J"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"1940592","DOI":"10.1155\/2018\/1940592","article-title":"Thromboembolic events secondary to endoscopic cyanoacrylate injection: can we foresee any red flags?","volume":"2018","author":"Tseng","year":"2018","journal-title":"Can J Gastroenterol Hepatol"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"447","DOI":"10.1016\/j.gie.2008.02.050","article-title":"Standardized injection technique ensures safety of cyanoacrylate therapy","volume":"68","author":"Seewald","year":"2008","journal-title":"Gastrointest Endosc"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"559","DOI":"10.1111\/hepr.12591","article-title":"Three-dimensional CT of portopulmonary venous anastomoses in esophageal varices","volume":"46","author":"Matsumoto","year":"2016","journal-title":"Hepatol Res"},{"key":"ref12","doi-asserted-by":"publisher","DOI":"10.14309\/ajg.0000000000003629","article-title":"Adding clip before endoscopic cyanoacrylate injection decreases ectopic embolisms in gastric varices: a randomized controlled trial","author":"Wang","year":"2025","journal-title":"Am J Gastroenterol"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"W70","DOI":"10.1097\/RTI.0b013e3181a652fa","article-title":"Computed tomography findings of spontaneous Porto-pulmonary shunts in portal hypertension","volume":"25","author":"Kumar","year":"2010","journal-title":"J Thorac Imaging"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"1034","DOI":"10.1055\/s-2005-870211","article-title":"Cortical blindness and acute myocardial infarction following injection of bleeding gastric varices with cyanoacrylate glue","volume":"37","author":"Upadhyay","year":"2005","journal-title":"Endoscopy"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"402","DOI":"10.1016\/j.gie.2007.03.008","article-title":"EUS-guided cyanoacrylate injection in gastric varices","volume":"66","author":"Romero-Castro","year":"2007","journal-title":"Gastrointest Endosc"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"479","DOI":"10.1148\/radiology.144.3.7100457","article-title":"Portopulmonary venous anastomosis in portal hypertension demonstrated by cine-portography","volume":"144","author":"Sano","year":"1982","journal-title":"Radiology"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"447","DOI":"10.1097\/00042737-200604000-00022","article-title":"A patient with portal hypertension and blindness after transjugular intrahepatic portosystemic shunt","volume":"18","author":"Appenrodt","year":"2006","journal-title":"Eur J Gastroenterol Hepatol"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"217","DOI":"10.1016\/j.jstrokecerebrovasdis.2010.08.001","article-title":"Multiple ischemic strokes after transcatheter arterial chemoembolization for hepatocellular carcinoma","volume":"21","author":"Zach","year":"2012","journal-title":"J Stroke Cerebrovasc Dis"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"212","DOI":"10.1093\/gastro\/goaa082","article-title":"Efficacy and safety of combined endoscopic cyanoacrylate injection and balloon-occluded retrograde transvenous occlusion (BRTOcc) of gastrorenal shunts in patients with bleeding gastric fundal varices","volume":"9","author":"Bazerbachi","year":"2021","journal-title":"Gastroenterol Rep"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"289","DOI":"10.2176\/jns-nmc.2025-0076","article-title":"Mechanical thrombectomy for N-butyl-2-cyanoacrylate cerebral embolism via portopulmonary venous anastomosis","volume":"12","author":"Maeda","year":"2025","journal-title":"NMC Case Rep J"}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1825258\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T15:12:47Z","timestamp":1779117167000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2026.1825258\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,18]]},"references-count":20,"alternative-id":["10.3389\/fmed.2026.1825258"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2026.1825258","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,18]]},"article-number":"1825258"}}