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24 To minimize the risk of embolism, patients should always be biopsied when lying horizontally. This complication is more likely when the lesion is near central pulmonary veins. Care should be taken to occlude the needle hub at all times during the procedure after removal of the stylet. Air embolism is possible when a communication is formed between a lung cavity or airway and an adjacent pulmonary vein; it is more likely in patients with diffuse lung disease and reduced lung compliance. Air may embolize to the coronary or cerebral circulation resulting in severe chest pain, fatal dysrhythmia, circulatory collapse, confusion, focal neurological deficit, seizures or decreased consciousness. The diagnosis RVX-208 can be confirmed by CT showing air in the left side of the heart, coronary arteries or intracranial vessels (Fig.?4). Treatment Selleck BMS777607 is with oxygen and anticonvulsants if necessary. The patient should be placed in the left lateral decubitus position if residual air is seen in the left side of the heart, otherwise in the Trendelenburg position. Steroids and aspirin may also be useful. Hyperbaric oxygen has been used successfully in one case.25 Haemothorax.? Significant haemothorax is rare but can occur after inadvertent laceration of the intercostal or internal mammary arteries.19 Intercostal vessels can usually be avoided by not using an immediately subcostal route and by avoiding a paravertebral approach. Major bleeding may require embolization or thoracotomy. If bleeding is significant signs are usually evident within the first hour. Tumour implantation.? Seeding of tumour along the needle track is rare but has been reported.10 This is more likely after the use of a cutting needle biopsy or thoracentesis of mesothelioma. It has been suggested that interference with the tumour by the needle tip could increase the Selleckchem Neratinib chances of haematogenous dissemination but there is no evidence to support this theory. Other complications.? Subcutaneous and mediastinal emphysema may occur but is rare and usually unimportant, usually occurring secondary to the production of a pneumothorax particularly if a chest drain has been required. Although empyema has been described10 this is very rare, even when the biopsy is being performed to confirm suspected infectious lesions. There have been several reported cases of haemopericardium26 leading to pericardial tamponade and arrest; pericardial aspiration can result in recovery. Percutaneous needle biopsy of mediastinal disease has been used for diagnosis of primary and secondary carcinoma, neoplastic, reactive and infectious nodal enlargement and mediastinal abscess collections. A cutting needle is preferred particularly if there is a suspicion of lymphoproliferative malignancy as histology of tissue cores is required for adequate characterization.