From Cervical Trauma and Head Injury to Malignant Cerebral Edema: Blunt Cerebrovascular Injury Causing Large-Vessel Occlusion Treated With Thrombectomy and Neurocritical Care

Blunt cerebrovascular injury (BCVI) is an uncommon but potentially life-threatening complication of cervical trauma that may lead to delayed ischemic stroke. Early diagnosis is often challenging because neurological symptoms may initially be absent or mild. We report a case of traumatic internal carotid artery dissection associated with cervical fracture that resulted in large-vessel occlusion and required both endovascular treatment and intensive neurocritical care. A 57-year-old woman fell down stairs and sustained cervical trauma. Initial computed tomography revealed a fracture of the atlas involving the transverse foramen without intracranial hemorrhage. Approximately four hours after the injury, she developed right hemiparesis, aphasia, and left conjugate deviation. Computed tomography angiography (CTA) demonstrated occlusion of the left internal carotid artery, left vertebral artery, and left middle cerebral artery. Magnetic resonance imaging revealed an acute infarction in the left middle cerebral artery territory and the left lateral medulla with diffusion-fluid-attenuated inversion recovery (FLAIR) mismatch. Mechanical thrombectomy achieved successful recanalization of the left middle cerebral artery. However, severe cerebral edema developed the following day, requiring emergency decompressive craniectomy and intracranial pressure (ICP) monitoring. Intensive neurocritical care, including osmotherapy, deep sedation, controlled ventilation, and temperature management therapy guided by ICP monitoring, was performed. Cerebral edema gradually improved, and cranioplasty was performed on Day 44. Three months after injury, the patient had persistent right hemiparesis and aphasia with a modified Rankin Scale score of 5. This case highlights the importance of early recognition of BCVI in patients with cervical trauma, particularly when fractures involve the transverse foramen. Even when successful reperfusion is achieved, aggressive neurocritical care, including ICP monitoring and temperature management, may be essential for managing severe cerebral edema.