Neurological symptoms and MRI changes post-sugammadex reversal

Although sugammadex revolutionized anesthesia with rapid, effective reversal of non-depolarizing neuromuscular blocking agents, post-marketing surveillance identified rare occurrences of neurological side effects. To our knowledge, we report the first case of transient neurological symptoms and abnormal MRI changes following sugammadex administration. A 65-year-old woman underwent endoscopic resection of gastric lesion under general anesthesia. Sugammadex was used to reverse the non-depolarizing neuromuscular blocking agents. Preoperatively, she was alert with intact neurological function but postoperatively, she developed multiple neurological deficits. Magnetic resonance imaging (MRI) with diffusion-weighted imaging showed faint hyperintensity in the right temporal cortex. Despite an improved neurological exam, repeat diffusion-weighted imaging MRI revealed evolving hyperintensity in her bi-temporal cortex, and she returned to her baseline without residual deficits. A follow-up MRI on day 21 showed complete resolution. Notably, she had undergone a procedure five months earlier in which sugammadex had been used as a reversal agent and short-term neurological defects had been reported. Since other etiologies can cause some of these symptoms, we examined the specific and overall clinical context and argue against neuroinflammation or infectious etiology. Notably, neurological symptoms occurred following the only two occasions in which sugammadex was used to reverse rocuronium, while no adverse effects were reported when rocuronium was reversed using neostigmine in previous procedures. The mechanism of sugammadex causing transient neurological symptoms with MRI changes is unclear, but rat nerve cell culture studies indicate a possibility of neurotoxicity. Keywords: Sugammadex, neuromuscular blocking agents, general anesthesia, neurotoxicity