Early Detection of Cerebral Embolism During Transcatheter Aortic Valve Replacement Facilitated by Rapid Awakening Through the Antagonism of Remimazolam With Flumazenil: A Case Report.

The combination of remimazolam and flumazenil facilitates the rapid acquisition of neurological findings immediately after awakening from anesthesia, potentially improving the likelihood of early detection of neurological complications during anesthesia. Cerebral infarction is a serious complication of transcatheter aortic valve replacement (TAVR), which can significantly impact a patient's quality of life and activities of daily living. Although complete prevention of cerebral infarction remains challenging, early detection and prompt treatment can improve the neurological prognosis. We present the case of an 83-year-old woman in whom a stroke was diagnosed immediately after TAVR. Prompt transcatheter revascularization was performed, leading to a favorable neurological outcome. The patient underwent transfemoral artery TAVR under sedation with remimazolam and remifentanil. A 26-mm Evolut Pro+ valve was placed in the planned position, and implantation was completed successfully. Following TAVR, the patient was awakened with flumazenil. Due to poor arousal, aphasia, and right-sided muscle weakness, she was referred to the neurology department for further evaluation. Approximately 10 minutes after the surgery was completed, a decision was made to perform a detailed evaluation of a potential stroke in the operating room. Imaging revealed an occlusion in the inferior division of the left middle cerebral artery. Successful recanalization was achieved through catheter-based thrombectomy 200 minutes after the procedure. The patient's postoperative course was favorable, except for some aphasia. She was discharged and able to live independently, without difficulty, similar to her condition before surgery. To detect cerebral infarction early, it is crucial to assess neurological status post-TAVR promptly. Rapid awakening from anesthesia and distinguishing between the effects of anesthesia and neurological deficits are essential. The combination of remimazolam and flumazenil can effectively and rapidly reverse the effects of anesthesia within about one minute after flumazenil administration, potentially facilitating the early detection of a stroke.