Refractory Macroglossia Following Thrombolysis and Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction: A Case Report from the Neurocritical Care Unit

Background: Macroglossia is an uncommon yet potentially life-threatening complication encountered in critically ill neurological patients, with an estimated incidence ranging from 0.5% to 5% following major neurosurgical interventions (1). The pathogenesis is typically multifactorial, involving mechanical compression, venous and lymphatic stasis, neurogenic influences, and drug-induced angioedema (4,5). Severe, persistent tongue enlargement can precipitate airway obstruction, impair nutritional support, and significantly prolong intensive care unit (ICU) stay (8). Case Presentation: We report a 65-year-old female with type 2 diabetes mellitus, hypertension, and hypothyroidism who developed a malignant right middle cerebral artery (MCA) territory infarction. Following intravenous tenecteplase administration, she experienced hemorrhagic transformation and subsequent decompressive hemicraniectomy. Her postoperative course was complicated by progressive, severe macroglossia refractory to multiple steroid injections and conservative measures. Comprehensive imaging, including contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), excluded necrosis or focal lesions, implicating diffuse edema secondary to venous congestion, lymphatic impairment, and local traumatic injury. The multidisciplinary team proposed surgical tongue reduction (odontectomy/debulking); however, the family declined due to perceived high operative risks. Conclusion: This case underscores the diagnostic and therapeutic challenges inherent in managing refractory macroglossia in the neurocritical care setting. Early recognition, systematic evaluation, and multidisciplinary collaboration are paramount. When conservative strategies prove futile and surgical intervention is precluded, the clinical course becomes exceptionally complex, often resulting in prolonged morbidity and functional impairment.