Intraoperative middle cerebral artery injury salvaged by intracranial stent placement during surgical resection of necrotizing neurosarcoidosis

• Main Authors: Darsh Shah, Akhil Surapaneni, Dayal Rajagopalan, Min Wang, Jefferson Miley, Ramsey Ashour
• Format: Article
• Language: English
• Published: Elsevier 2021-06-01
• Series: Interdisciplinary Neurosurgery
• Subjects: Neurosarcoidosis; Perioperative stroke; Mechanical thrombectomy; Intracranial stent; LVIS Jr
• Online Access: http://www.sciencedirect.com/science/article/pii/S2214751920306095

Background: Intraoperative middle cerebral artery injury during cranial neurosurgery is a harrowing complication; the overall outcome depends on the nature of the injury and the steps taken to handle it. If direct repair is unsuccessful, traditionally either the expected stroke must be accepted or a bypass must be performed to prevent it, which is often challenging or not feasible if not planned prior to the procedure. Case presentation: A 57 year-old woman with necrotizing neurosarcoidosis presented with headaches and left hemiparesis and was found to have a large right frontotemporal intra-axial mass, progressive in spite of steroids. During surgical resection, the inferior M2 middle cerebral artery (MCA) division was injured. In spite of microsurgical repair of the vessel, the patient emerged from anesthesia with complete left hemiplegia. Emergent cerebral angiography confirmed complete occlusion of the inferior M2 MCA division. Mechanical thrombectomy with a stent-retriever was performed twice, each time resulting in transient recanalization of the vessel followed by re-occlusion. An LVIS Jr. stent was then deployed across the injured segment, intravenous eptifibatide drip initiated, and dual antiplatelet therapy commenced. The patient improved immediately on the table, moving her left side against gravity. Angiography six months later showed continued patency of the injured vessel. At 1-year postoperatively, the patient was back to work with minimal deficits and good control of her sarcoidosis on immunotherapy. Conclusion: This report highlights a rare case of necrotizing neurosarcoidosis, treated surgically, with intraoperative MCA injury salvaged by microsurgical and subsequent endovascular repair with an intracranial stent. Key aspects of complication management are highlighted.