Intraoperative stroke in the mandibular osteoradionecrosis: A case report

Although risk factors for perioperative stroke during head and neck surgery are known, the risk of perioperative stroke in osteoradionecrosis (ORN) patients is scarcely known. Sixty-seven-year-old male presented ORN in the mandible after 9 years docetaxel, cisplatin, and 5-fluorouracil (TPF) chemo, and 66 Gy radiation therapies for the oropharynx cancer, which was diagnosed Marx's classification class II. After pre-operative hyperbaric oxygen (HBO) therapy, trans-oral debridement, iliac cancellous bone grafting, and a primary mucosal closure were performed under general anesthesia. Left-hemiplegia, dysarthria, and left facial palsy were observed at a recover room after the surgery. MRI revealed a cerebral infarction on the right middle cerebral artery (MCA) region. CT angiography showed that the severe stenosis of the right internal carotid artery (ICA). Ultrasound of carotid artery also revealed that the degree of the right ICA stenosis was 67%. Holter-monitoring showed no atrial fibrillation, and echocardiogram showed no cardiac source of thromboembolism. Atherothrombotic brain infarction caused by thrombus in the atherosclerosis ICA to MCA was diagnosed in this case. Routine duplex ultrasound carotid-artery screening before surgery for ORN patient was strongly recommended.