Intraoperative Magnetic Resonance Imaging Complications Leading to Remote Intracerebral Hemorrhagic Infarction Following a Glioblastoma Resection: A Case Report and Lessons for Clinical Practice.

Glioblastoma is the most aggressive primary brain tumor, requiring a multidisciplinary strategy with an emphasis on "maximal safe resection" to improve outcomes. Intraoperative magnetic resonance imaging (iMRI) enables real-time assessment of tumors and helps preserve eloquent brain areas. While generally safe, rare complications may arise. We report a rare case of remote hemorrhagic infarction after glioblastoma resection using iMRI, possibly linked to mechanical compression from intraoperative gauze. A 50-year-old male patient with progressive aphasia had a maximal diameter of 55 mm contrast-enhancing lesion in the left medial temporal lobe, consistent with glioblastoma. Resection with iMRI was uneventful, and imaging confirmed total removal without ischemia or hemorrhage. Before iMRI, gauze was inserted into the epidural space, and the skin was temporarily closed. Postoperatively, the patient developed new aphasia and right hemiparesis. Emergency imaging 12 hours after surgery showed a hemorrhagic infarction in the ipsilateral precentral and inferior frontal gyri, remote from the surgical site. Retrospective review of iMRI indicated significant brain compression and venous dilation, suggesting impaired venous return during the 30-minute iMRI scan led to infarction from venous congestion or reperfusion injury. To our knowledge, this is the first report implicating iMRI-related brain compression in remote venous infarction, underscoring the need for cautious intraoperative brain handling to prevent such complications.