Irreversible Brainstem Atrophy After Fibrin-Sealant Hypersensitivity: A Neurorehabilitation Perspective: A Case...

Hypersensitivity reactions to fibrin sealants used in microvascular decompression (MVD) are rare, and delayed eosinophilic meningoencephalitis with progressive brainstem injury has been scarcely reported. We present a case of severe delayed immune-mediated brainstem injury following fibrin-sealant application during MVD for trigeminal neuralgia, with an emphasis on its neurorehabilitation implications. A male patient with long-standing trigeminal neuralgia underwent MVD using a Teflon pledget secured with Beriplast^® fibrin sealant. Immediately after surgery, he developed profound quadriplegia (Medical Research Council [MRC] grade 1 in all extremities). Magnetic resonance imaging on postoperative day (POD) 0 revealed ventral medullary and pontine T2/FLAIR hyperintensity without diffusion restriction, consistent with acute vasogenic edema. Despite complete surgical material removal on POD 1, deficits persisted. By POD 8, new diffusion-restricted lesions appeared, indicating secondary cytotoxic injury. Delayed eosinophilia peaked at 21.0% on POD 62, accompanied by a diffuse rash. Comprehensive workup excluded vascular, infectious, autoimmune, and drug-related causes. On transfer to our rehabilitation center (POD 251), motor strength was MRC 3+ in upper and 2- in lower extremities; the patient remained wheelchair-dependent with severe functional limitation and required assistance for all activities of daily living. Markedly prolonged somatosensory evoked potential and motor evoked potential latencies confirmed irreversible corticospinal and sensory pathway disruption, suggesting a potential ceiling for neuroplasticity-driven recovery in this case. Despite one month of structured inpatient neurorehabilitation, no meaningful functional gain was achieved. This case underscores the importance of early immune-mediated injury recognition and highlights the critical role of neurophysiological assessment in prognostication and rehabilitation goal-setting following catastrophic brainstem injury.