Author: Portela e Silva R et al.
Cureus 17(10), October 2025. DOI: 10.7759/cureus.95775
This case report describes a 79-year-old woman with atrial fibrillation on oral anticoagulation who experienced a sudden loss of consciousness in the operating room just before induction for emergent thromboembolectomy for acute limb ischemia. Initially awake and alert, she abruptly developed apnea and a Glasgow Coma Scale of 3. Neurological examination showed nonreactive pupils and absent corneal reflexes, but hemodynamics remained stable. Computed tomography and angiography of the head and neck revealed no acute lesions or major vessel occlusions. The patient began regaining consciousness within 20 minutes, and neurologists determined the most likely diagnosis was a vertebrobasilar transient ischemic attack (TIA) with spontaneous reperfusion.
The episode underscores how vertebrobasilar ischemic events can present dramatically — including coma — yet resolve rapidly, making diagnosis difficult in perioperative settings. Atrial fibrillation remains a major source of systemic thromboembolic events, and anticoagulation, while reducing risk, does not eliminate it. The coexistence of acute limb ischemia and cerebral ischemia in this case emphasizes the need for vigilance when managing anticoagulated patients with active embolic phenomena. The authors highlight that if the neurological event had occurred during anesthesia, diagnosis and timely stroke treatment could have been delayed, increasing the risk of poor outcomes.
What You Should Know
Even in anticoagulated patients with atrial fibrillation, concurrent embolic events involving the brain and limbs can occur. A sudden loss of consciousness before or during surgery should prompt urgent neurological evaluation and imaging to rule out posterior circulation ischemia. Rapid recognition and coordinated care are essential, as timely intervention greatly improves recovery potential.
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