Neurological injury after breath-hold diving related to gas bubble in brain

ImageIt is well documented that repeated breath-hold diving may cause neurological symptoms and even permanent brain injury.  The nature of these injuries has been debated since the first anecdotal report of taravana, symptoms similar to decompression sickness (DCS), among breath-hold divers at Tuamotu Archipelago. Since then DCS-like symptoms (primarily neurological) have been described and documented among many other groups of breath-hold divers like Ama divers of Japan, Mediterranean sport spearfishermen and competitive breath-hold divers worldwide.

The theoretical calculations of nitrogen saturation and desaturation during repeated breath-hold dives have shown that some dive patterns can create conditions for DCS. Extension of the surface interval between the two breath-hold dives appears to prevent neurological symptoms. For some experts, this supports the opinion that taravana is caused by DCS. Others suggest that the protective effect of the longer surface interval supports their hypothesis that taravana is caused by hypoxia alone.

Attempts to demonstrate circulating gas bubbles (venous gas emboli, VGE) in breath-hold divers were unsuccessful for many years. Recently, Koshi K, et al.1 used precordial Doppler to monitor for circulating bubbles postdive in 12 professional Ama divers. In one diver they found VGE Spencer grade I, meaning that they detected one or few bubbles over 10 cardiac cycles. The diver who was positive for bubbles did not have any symptoms, but four other divers in the group experienced transient neurological symptoms without positive bubble findings. While the circulating bubbles in breath-hold divers seem elusive, another group of Japanese authors provided different evidence for DCS in breath-hold divers (Matsuo R, et al.2). They reported a case of a Japanese breath-hold diver (Ama), who presented neurological disorders after repeatedly diving 25-30 meters deep for 6 hours. He experienced dizziness and an unsteady gait. Neurological examination showed objective findings corresponding to his symptoms. The patient underwent a head CT, which revealed gas bubbles in the left parietal lobe of the brain. He was diagnosed as having neurological decompression illness and treated with hyperbaric oxygen therapy. In a CT scan that was repeated three days after onset, gas bubbles disappeared and low-density areas were observed in where they were before. Tests for pulmonary barotrauma and intracardiac shunt were negative. The authors concluded that microbubbles that cause decompression injury to the brain were the culprit in this case.

To my knowledge, this is the first direct evidence that post-decompression free gas causes neurological symptoms. While this evidence may not be universally accepted, I now readily acknowledge that decompression sickness is one if not the only cause of neurological symptoms in breath-hold divers.

  1. Kohshi, K; Lemaitre, F; Tamaki, H; Nakayasu, K; Harada, M; Okayama, M; Satou, Y; Hoshiko, M; Ishitake, T; Wong, RM. Intravascular bubbles and diving patterns in Japanese Ama divers. Undersea and Hyperbaric Medical Society (UHMS) Annual Meetings. Abstract.
  2.  Matsuo R, Arakawa S, Furuta Y, Kanazawa Y, Kamouchi M, Kitazono T. Neurological decompression illness in a Japanese breath-hold diver: a case report]. Rinsho Shinkeigaku. 2012;52(10):757-61. [Article in Japanese]

Related Topics:

Effects of Diving on the Brain

Post written by: Petar Denoble, MD, D.Sc.


    1. Breath-hold diving is submerging underwater depending on air in your lungs and oxygen available in your body, without possibility to breath. Since the oxygen is used all the time, it will reach critically low level within minutes and diver must emerge to take another breath and take a new supply of oxygen.

      1. So am I to understand that diving with a supply of air and holding breath while maintaining constant depth, and then inhaling a new breath is not considered breath-holding in the context of this article?

      2. That is correct. The article did not consider holding your breath underwater while having access to a compressed gas source. That would be a risky thing to do. It is not advisable practice. I know of several fatalities that occurred when two divers went to dive on one tank, which at any moment had one of them holding the breath after inhaling a compressed gas. The cause of fatality was pulmonary barotrauma and cerebral arterial gas embolism.

  1. Interesting article, could you link which studies are you referring to related to the “well documented that repeated breath-hold diving may cause neurological symptoms and even permanent brain injury.”

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