Case reportHemorrhagic complications of intraoperative neurophysiologic monitoring needle electrodes

•The rare occurrence of a hemorrhagic complication secondary to a subdermal needle electrode is described.•This case underscores the importance of monitoring and risk minimization in regards to hemorrhagic complications, especially in patients who are anticoagulated and receiving dual antiplatelet therapy, during neurointerventional procedures.•Hemorrhagic complications associated with subdermal needle electrodes, though rare, can have significant consequences in patients.

BackgroundIntraoperative neurophysiologic monitoring is a commonly used adjunct during many neurointerventional procedures.ObjectiveHere we describe the rare occurrence of a hemorrhagic complication secondary to a subdermal needle electrode.MethodsA 67 year old male with a left-sided fusiform vertebrobasilar aneurysm was scheduled to undergo placement of a pipeline embolization device. The patient had been administered aspirin 325 mg and Plavix 75 mg daily for greater than one week preoperatively. After successfully undergoing endotracheal intubation, 7 mm length and 0.4 mm diameter subdermal needle electrode intraoperative monitoring leads were placed in the scalp, mastoid and bilateral Erb's points Following successful completion of the procedure, but prior to extubation and closure of the femoral arterial site, the patient was noted to have a significant amount of swelling in the left neck and supraclavicular region in the immediate vicinity of the left Erb's point subdermal needle electrode. Review of the last angiographic run in the region noted active extravasation from a muscular branch of the suprascapular artery immediately subjacent to the aforementioned subdermal electrode. The literature has been reviewed and recommendations for management and surveillance are made.ResultsThis case underscores the importance of monitoring and risk minimization in regards to hemorrhagic complications, especially in patients who are anticoagulated and receiving dual antiplatelet therapy, during neurointerventional procedures.ConclusionHemorrhagic complications associated with subdermal needle electrodes, though rare, can have significant consequences in patients.