The Clandestine Slayer: A Case Report on Carotid Artery Injuries in Traumatic Brain Injury

Abstract

Traumatic carotid artery injury is a rare yet potentially fatal complication of head and neck trauma. Often masked by primary brain injury, it may remain undiagnosed until the onset of devastating neurological consequences. We present two contrasting cases of traumatic brain injury with carotid artery injury—one where the injury was missed initially, leading to malignant infarction and death, and another where timely detection resulted in a favorable outcome. These cases underscore the importance of heightened clinical suspicion and standardized screening for carotid artery injury in specific trauma patterns, especially in patients presenting with high-risk mechanisms or unexplained neurological deterioration.

 

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Keywords

blunt trauma - carotid injury - neck injury - screening - traumatic brain injury

Introduction

Traumatic carotid artery injury (TCAI) is reported in approximately 1% of patients with severe head trauma.[1] [2] Despite its low incidence, the clinical sequelae can be severe, with complications such as thromboembolic stroke, pseudoaneurysm formation, and malignant infarction contributing significantly to morbidity and mortality. One series reported permanent neurological impairment in nearly 40% of patients, while 30% succumbed to their injuries.[3]

Early identification and management are crucial, as delayed diagnosis often results in poor outcomes.[4] However, the covert nature of many carotid injuries, especially in the absence of overt signs, can pose a diagnostic challenge. In this report, we present two cases of traumatic brain injury (TBI) with concomitant carotid injury—one undiagnosed until after infarction, and the other identified early highlighting the importance of early vascular imaging in selected trauma cases.

 

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Case Report

Case 1: Missed Carotid Injury Leading to Malignant Infarction

A 40-year-old previously healthy male was brought to the emergency department with a history of physical assault involving blunt trauma to the head and body. The patient experienced a transient loss of consciousness followed by multiple episodes of vomiting and left-sided ear bleed. Initial assessment revealed a Glasgow Coma Scale (GCS) score of E1V1M5 Pupils B/L reactive. Imaging demonstrated a left frontal acute subdural hematoma (8 mm), left temporal acute epidural hematoma (5 mm), sulcal subarachnoid hemorrhage ([Fig. 1]), left mandibular fracture, left orbital wall fracture, and sphenoid sinus fracture with hemosinus.

Fig. 1 CT head (axial) of a left frontal acute subdural hematoma (8 mm), left temporal acute epidural hematoma (5 mm), and sulcal subarachnoid hemorrhage. CT, computed tomography.

The patient was managed conservatively in the intensive care unit with an intracranial pressure (ICP) monitor inserted after the patient was intubated. Over 24 hours, persistent ICP elevation warranted repeat neuroimaging, which revealed a developing left hemispheric infarct. Emergency decompressive fronto-temporo-parietal craniectomy was performed. A subsequent computed tomography (CT) angiogram (CTA) revealed an underlying left internal carotid artery injury ([Fig. 2]), likely responsible for the malignant infarction. Despite intensive care and tracheostomy, the patient developed sepsis and eventually succumbed to his illness.

Fig. 2 (A) CT head (axial) of a developing left hemispheric infarct. (B) CT angiogram revealed an underlying left internal carotid artery injury. CT, computed tomography.

 

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Case 2: Timely Diagnosis and Favorable Outcome

A 44-year-old male sustained head trauma following a road traffic accident. He had a visible incised wound over the right side of the neck. Initial GCS was E4V5M6. CT head revealed small cerebral contusions without midline shift or mass effect. Due to the presence of a penetrating neck injury, a CTA was performed, which revealed a partial injury to the right internal carotid artery. The patient was managed conservatively under close neurological monitoring. No neurological deterioration occurred, and serial CTs remained stable. The patient had an uneventful recovery and was discharged in a stable condition.

 

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Discussion

TCAI is a frequently underdiagnosed entity with significant clinical implications. While uncommon, it disproportionately affects the young adult population and is most often associated with road traffic accidents, falls from height, or assault-related trauma.[1] [3]

In many cases, diagnosis is only made after the patient presents with stroke or other irreversible neurological damage.[4] The two cases presented herein highlight the stark contrast in outcomes depending on the timing of diagnosis. In case 1, the injury was clinically occult and not initially suspected. Delayed recognition led to a malignant infarction requiring decompressive surgery and eventual patient death. Conversely, in case 2, the presence of an obvious neck wound triggered a timely vascular imaging study, allowing early diagnosis and conservative management with a good prognosis.

Screening strategies remain inconsistent across institutions. Biffl et al[1] emphasized the importance of early identification and proposed a grading scale for blunt carotid injury (BCI), which has informed clinical decision-making over time. Kerwin et al[2] advocated for liberal screening using CTA in patients with high-risk features such as cervical spine or skull base fractures, Le Fort facial fractures, or unexplained neurological findings.[5]

Anticoagulation therapy, particularly with intravenous heparin, has shown to reduce ischemic complications in lower grade injuries, as highlighted by Fabian et al.[3] Nonetheless, the presence of polytrauma injuries necessitates a careful risk-benefit assessment. Maiese et al[4] further discussed the medico-legal importance of diagnosing these injuries early, as missed or delayed diagnoses could have legal ramifications, especially in preventable fatal outcomes.

From a neurosurgical perspective, TCAIs are particularly concerning in the context of TBI. Overlapping signs of cranial base fractures, brain contusions, and mass effect can easily mask vascular injuries. We are often involved in the initial assessment and must advocate for early vascular imaging in patients with unexplained neurologic deterioration or in those with high-risk fracture patterns. Moreover, in patients undergoing cranial or spinal decompression for trauma, knowledge of concomitant BCI can influence perioperative anticoagulation strategies and surgical planning.

The advent of endovascular techniques has added an additional dimension to the management of higher grade BCIs. While low-grade injuries (Grade I/II) are generally managed with antithrombotic therapy, higher grade lesions (Grade III–V), including pseudoaneurysms and occlusions, may require stenting or embolization. However, indications for intervention remain somewhat controversial and should be individualized based on angiographic findings, hemodynamic status, and associated injuries.

We should maintain a high index of suspicion and advocate for early vascular imaging especially CTA in trauma patients with high-risk mechanisms, unexplained infarcts, or clinical-radiologic dissociation.

 

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Conclusion

TCAI remains a potentially fatal but often underdiagnosed complication in TBI. These two cases underscore the critical importance of early screening, particularly in patients with suggestive trauma patterns or unexplained neurologic deterioration. A systematic approach incorporating high-risk trauma identification, liberal CTA use, and multidisciplinary management can significantly improve patient outcomes. Institutional protocols and national guidelines should be developed to facilitate timely diagnosis and management, potentially reducing morbidity, mortality, and medico-legal consequences.

 

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Conflict of Interest

None declared.

• References

• 1 Biffl WL, Moore EE, Ryu RK. et al. The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome. Ann Surg 1998; 228 (04) 462-470
• 2 Kerwin AJ, Bynoe RP, Murray J. et al. Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma 2001; 51 (02) 308-314
• 3 Fabian TC, Patton Jr JH, Croce MA, Minard G, Kudsk KA, Pritchard FE. Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy. Ann Surg 1996; 223 (05) 513-522 , discussion 522–525
• 4 Maiese A, Frati P, Manetti AC. et al. Traumatic internal carotid artery injuries: do we need a screening strategy? Literature review, case report, and forensic evaluation. Curr Neuropharmacol 2022; 20 (09) 1752-1773
• 5 Shields J, De Stefano F, Fry L, Ebersole K, Peterson J. A bibliometric analysis of blunt cerebrovascular injury: the top 50 most instrumental articles. Neurosurg Rev 2025; 48 (01) 336

Publication History

Article published online:
13 June 2025