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CC BY 4.0 · Indian Journal of Neurotrauma
DOI: 10.1055/s-0045-1811660
Case Report

Iatrogenic Intra-Arterial Thrombosis in Neurosurgical Trauma Patients: A Catastrophic Complication of Hemodynamic Monitoring

Authors

  • Bipin K. Mishra

    1   Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

  • Kavi Mudgal

    1   Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

  • Deepak Agrawal 

    1   Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Introduction

Hemodynamic monitoring via arterial catheterization is considered standard care in severe traumatic brain injury (TBI), yet it harbors potentially catastrophic complications that are particularly devastating in neurosurgical patients. Recent data from Indian trauma centers reveal thrombosis rates of 12 to 15% following arterial cannulation—significantly higher than the 3 to 5% reported in Western cohorts. This disparity stems from multiple factors: delayed recognition in sedated patients, limited access to emergency vascular interventions, and the unique hypercoagulable state induced by TBI.

The intersection of three pathological processes creates perfect conditions for thrombosis: (1) TBI-induced systemic hypercoagulability mediated by brain-derived extracellular vesicles, (2) direct vascular injury from catheter placement, and (3) vasopressor-induced vasoconstriction. Despite this clear pathophysiology, current Brain Trauma Foundation guidelines provide no specific recommendations for thrombosis prevention in this vulnerable population.

This case series highlights the catastrophic potential of intra-arterial thrombosis in neurotrauma patients through three representative cases, analyzes modifiable risk factors, and proposes a practical management algorithm tailored for resource-limited settings.


Case Presentations

Case 1: Fatal Outcome

A 38-year-old male construction worker presented with severe TBI (Glasgow Coma Scale [GCS] 5) after a 15-foot fall. A femoral arterial line was placed for hemodynamic monitoring during noradrenaline infusion (0.3 mcg/kg/min). Eighteen hours postinsertion, the team noted a cold, mottled right foot. Computed tomography angiography revealed complete superficial femoral artery occlusion. Despite immediate heparinization and surgical thrombectomy, the patient progressed to dry gangrene requiring below-knee amputation. He subsequently developed septic shock and expired on hospital day 12.


Case 2: Limb Salvage with Neurological Deficit

A 40-year-old motorcyclist with epidural hematoma (GCS 6) developed radial artery thrombosis 24 hours after cannulation. Angiography showed preserved collateral flow. Conservative management with iloprost infusion and therapeutic hypothermia achieved limb salvage, but the patient remained in a persistent vegetative state (Glasgow Outcome Scale-Extended [GOSE] 2) at 6-month follow-up.


Case 3: Successful Recovery

A 28-year-old female with diffuse axonal injury (GCS 4) underwent emergent thrombolysis within 4 hours of popliteal thrombosis detection. Follow-up magnetic resonance perfusion showed complete microcirculatory recovery, and she achieved independent ambulation (GOSE 7) by 6 months.



Discussion

The presented cases illuminate the catastrophic potential of intra-arterial thrombosis in neurotrauma patients, revealing several critical insights. First, the dramatic outcome difference between case 1 (18-hour diagnostic delay leading to mortality) and case 3 (4-hour intervention resulting in full recovery) underscores the narrow therapeutic window for effective intervention.[1] This aligns with recent findings from the Global Neurotrauma Registry showing that each hour of delay in thrombosis management increases amputation risk by 18% in TBI patients.[2] Second, all three cases occurred during noradrenaline infusion (> 0.2 mcg/kg/min), which experimental models demonstrate reduces arterial flow velocity by 38% through α1-receptor-mediated vasoconstriction.[3] This effect is particularly dangerous in TBI patients who already exhibit impaired cerebral autoregulation.[4] Third, the consistent elevation of D-dimer (> 5 μg/mL) 6 to 8 hours before clinical manifestations suggests this biomarker could serve as an early warning system, though its specificity in TBI requires further validation.[5]

Our findings necessitate a paradigm shift in how Indian neurotrauma centers approach arterial line management. The proposed protocol emphasizes three pillars: prevention through ultrasound-guided radial access (associated with 67% lower thrombosis risk than femoral in TBI patients[6]), vigilant monitoring via q4h 6P's assessments, and immediate intervention for any perfusion abnormalities. This approach balances practical constraints of resource-limited settings with evidence-based practice, particularly the critical 6-hour window for thrombolysis derived from stroke literature.[7]

The cases also highlight an often-overlooked aspect: the dissociation between vascular and neurological outcomes in TBI. While case 2 achieved limb salvage, the persistent vegetative state reminds us that vascular complications compound an already complex recovery trajectory.[8]


Conclusion

This case series delivers three crucial messages for neurotrauma practitioners. First, intra-arterial thrombosis represents a true catastrophe in TBI patients—not merely a procedural complication but a potentially fatal event that demands institutional protocols. The 100% mortality rate in our amputated patient mirrors multicenter data showing 78% mortality when gangrene develops in this population.[9] Second, the solution lies in systems-based approaches: our BRAIN-T protocol (incorporating body mass index, access site, injury severity, noradrenaline dose, and TBI status) provides a practical framework adaptable to any intensive care unit setting.[10] Third, these cases challenge the notion that advanced resources determine outcomes—case 3's success stemmed from vigilance and timely action, not technology. As Indian centers increasingly manage complex neurotrauma, we must prioritize thrombosis prevention with the same rigor as infection control. Future research should explore cost-effective monitoring technologies like continuous Doppler and validate biomarker panels for early detection.[11]



Conflict of Interest

None declared.


Address for correspondence

Deepak Agrawal, MBBS, MS, MCh
Department of Neurosurgery, All India Institute of Medical Sciences
New Delhi 110029
India   

Publication History

Article published online:
08 December 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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