Received: March 20, 2025

Accepted: June 16, 2025

Ref: Tsranchev I , Timonov P , Yancheva S , Hadzhieva K , Gudelova T , Sotirova M , Fasova A , Dzhambazova E , Uchikov P.  Posttraumatic Ischemic Brain Stroke After Sharp Neck Injury: A Case Report Based on Autopsy.  Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], Vol. 27, No. 1 (January - June 2026): [about 11 p]. Available from:  https://www.anilaggrawal.com/ij/vol-027-no-001/papers/paper001

Published as Epub Ahead: June 25, 2025

DOI: 10.5281/zenodo.15743623

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Email- tsranchev@inbox.ru

[Epub Ahead]

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Posttraumatic Ischemic Brain Stroke After Sharp Neck Injury: A Case Report Based on Autopsy

Abstract

Neck injuries usually are emergency medical conditions which require special medical attention. Several complications following neck trauma could be fatal, if they are not correctly treated and diagnosed.  Present case is of a 56-year- old male patient sustained sharp neck trauma, who was immediately admitted for hospital treatment, with following surgical reconstruction of the left carotid artery. Two days after the surgical intervention, the patient showed clinical signs of coma and sudden respiratory and cardiac failure, resulting in a lethal outcome. Autopsy and microscopic findings revealed a life-threatening post-traumatic complication following such type of trauma. In each case of sharp or blunt neck trauma, the diagnosis “post-traumatic ischaemic brain stroke” must be ruled out as a possible serious complication by a detailed examination, including laboratory, ultrasonography, contrast angiography and various specific imaging methods. All these medical actions as standard medical algorithm can save the patient’s life.

Keywords:

Neck injury, posttraumatic brain stroke, sharp force trauma, fatal outcome, medico-legal case

Introduction

In routine forensic practice, various types of trauma can contribute to neck injuries, potentially leading to severe consequences or even a fatal outcome for the patient. Death could be directly attributed to the source of the injury or as a result of a complication following such a neck injury [1]. One possible cause of death can be a post-traumatic ischaemic brain stroke after blunt or sharp neck trauma involving blood vessels in the neck, which supply the brain with blood, which in turn can be a reason for blood clots and/or emboli, causing critical cerebrovascular blood flow blockage and death of brain tissue. In these emergency cases, if such an injury to the arteries can be diagnosed at the time after the trauma, a patient could be treated with different types of anti-clotting medications to prevent thrombosis and potential stroke formation, thus saving the patient's life.

Case Presentation

A 56-year-old male patient after excessive alcohol consumption fell to the floor in a bar and injured his neck on pieces of a broken glass. Immediately after, he was transported by emergency medics to the University Hospital "St George", Plovdiv, Bulgaria. After a detailed emergency room assessment, he was transferred to the Department of Vascular Surgery with the diagnosis of an "incised wound in the neck region with severance of the left carotid artery." An emergency reconstruction of the vessel wall was performed. Two days after the surgical intervention, the patient presented with clinical signs of coma and sudden respiratory and cardiac failure, resulting in a lethal outcome. After death, the body was transferred to the Department of Forensic Medicine for routine forensic examination. During the examination of the cadaver in the autopsy room, it was observed that on the frontal surface of the neck, in its upper third, just below the tip of the chin and slightly to the left, a slit-shaped incised wound was found, which had been surgically treated and stitched with 4 sutures. The length of the wound was 5cm. The edges of the wound were relatively clean and smooth; the edges were sharp. On the left half of the frontal surface of the neck, in the upper, middle and lower thirds, a large zigzag wound was found, stitched with 15 sutures. The length of the wound was 17 cm. The edges of the wound were also relatively smooth and clean, slightly congested, with scattered necrotic areas (Fig. 1). The wound was additionally assessed by performing several deep surgical cuts. A slit-shaped wound, 1 cm long and treated with one stitch, was found 2 cm to the left of the zigzag wound in the middle third of the neck.

The skin in the neck area was carefully dissected, and the zigzag wound was examined in depth. The muscles in the left half of the neck were diffusely blood-soaked with a dark reddish colour. The middle third of the sternocleidomastoid muscle had impaired integrity and had undergone surgical suturing. The muscle was dissected, and the left carotid artery was reached. It was found that a 2.5 cm long section from the common carotid artery to the carotid sinus was replaced by an artificial Dacron-type prosthesis. The left common carotid artery was opened during the autopsy, and at the upper end of the inserted prosthesis, a greyish-reddish dense thrombus was found inside, adhered to the prosthesis-vessel transition (Fig. 2). The thrombus occluded the lumen of the carotid artery by about 90%. Along the course of the external carotid artery at its beginning, two transverse tears in its intima with lengths of 0.2 and 0.4 cm were found. There was a tear in the wall of the left jugular vein at the level of the described carotid artery prosthesis. The tear is sutured. Its length was 0.5 cm.

During the internal examination of the cadaver, all soft tissues forming the scalp were intact, with a moist surface and a pale pink colour. The bones of the cranium were intact. The dura mater was pearly in colour and had a smooth surface. The cerebral gyri were smoothed, and the sulci were narrowed. In the left parieto-temporal region, there was a section of the cerebral cortex, sunken below the level of the surrounding brain tissue, with a pale greyish-yellowish colour, sized 4cm by 3.5 cm. We fixed the brain in a 10% formaldehyde solution for 48 hours before conducting a detailed examination.

The cerebral vessels at the base of the brain were well developed without malformations. A detailed examination revealed a hard, greyish-reddish thrombus occulting the left middle cerebral artery. Consecutive sections of the brain were made. In the left parieto-temporal region of the brain, a large area of ​​softening with a livid-greyish colour was found, with peripheral reddish haemorrhages (infarction) around it. The border between the grey and white brain matter was obliterated (Fig. 3). This area measured approximately 8 cm x 7 cm as dimensions on the surface of the left cerebral hemisphere with depth  measured 7 cm in the left cerebral hemisphere. The left middle cerebral ventricle narrowed, and the left cingulate gyrus (gyrus cinguli) was shifted to the right.

In the hypothalamus in the left cerebral hemisphere, a dark reddish round haemorrhage measuring 0.5 cm x 0.5 cm was also found. A similar haemorrhage was found in the basal nuclei of the left hemisphere, measuring 1 cm x 0.5 cm. Along the course of the brainstem (pons and medulla oblongata), numerous dark reddish haemorrhages measuring from punctate to 0.5 cm in diameter were found. In cross-section, the cerebellum was clear and normally developed.

Samples from brain matter were taken, and further microscopic examination was performed with H-E staining under Primo Star Zeiss microscopes with enlargements of 10x, 40x, and 100x. The detailed microscopic examination showed haemorrhages, oedema and multiple massive punctate haemorrhages in the left frontal cortex with multiple massive punctate haemorrhages in the left parietal cortex (Fig. 4), in combination with hyperaemia of blood vessels in the arachnoid layer. Additional microscopic findings were stated during this examination as follows: corpus callosum – mild oedema, hypothalamus – massive punctate haemorrhages and mild oedema, pons – areas with haemorrhages and severe oedema, medulla oblongata – severe oedema, cerebellum – oedema, cortex – mild oedema 2. Carotid artery vessel wall – part of a vessel with mixed thrombus (fig. 5). Other samples from internal organs showed no significant pathologic changes.

Discussion

Ischaemic strokes resulting from carotid artery thrombosis following open and closed head and neck trauma have been recognised with increasing frequency recently, and these cases involve not only adults but even children [2-6]. They can lead to life-threatening consequences or even a fatal outcome if they are not diagnosed correctly [7-10]. Ischaemic strokes resulting from carotid artery thrombosis are observed in both blunt and sharp injuries, such as in the case report described above. Carotid artery thrombosis is a rare but potentially devastating complication that can follow even reconstructive surgery of any major traumatised blood vessel of the neck region [11, 12].

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The non-traumatic genesis of carotid artery thrombosis, which can lead to ischemic stroke, should also be considered in such cases. The most common cause of non-traumatic carotid artery thrombosis is atherosclerosis [13]. In the presence of an unstable atherosclerotic plaque or an ulcerated atherosclerotic plaque, the endothelium of the arteries is compromised. In these cases, coagulation factors are activated, which predisposes to the formation of thrombi. In our case report during the autopsy, no atherosclerosis of the carotid arteries was detected. Other factors, of a non-traumatic nature, also predispose to the formation of thrombi in the body, such as obesity, pregnancy, smoking, arterial hypertension, and hyperlipidemia. Our case lacks previous patient history on whether the patient had any of the above-listed diseases based on medical documentation, and no pathological changes or malformations of the vessels in the brain were identified during the autopsy and on microscopy. Other causes of ischemic stroke are emboli. Most often, emboli form in the heart in the area of ​​a post-infarction aneurysm, in the left auricle of the heart in patients with ventricular fibrillation, and in patients with bacterial endocarditis. No such conditions were found in our case report. Taking certain medications, such as oral contraceptives, can cause blood clots to form in women.

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Different mechanisms can cause traumatic internal carotid artery thrombosis, including direct traumatic force delivered to the neck, the head, or the oral cavity, resulting in trauma to the soft tissues or even to the cranial bones, other possible mechanisms are whiplash trauma, seatbelt trauma or even procedures in the neck region [14].

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Studies have shown that factors significantly increasing the risk of developing carotid thrombosis due to carotid artery injuries include non-penetrating head injury, basilar fractures of the skull, facial fracture, cervical spinal fractures and thoracic injuries [15], with the non-penetrating head injury being the most common single associated injury. In the literature is suggested that combined injuries to the upper part of the body /head and neck injuries especially skull and spinal fractures and combined injuries to the head and chest/ increase the risk of damage to the carotid arteries. In our case the patient did not sustain any other trauma, except to the neck.

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In this case, we concluded that the cause of death is an ischaemic brain stroke caused by vascular injury resulting from sharp force trauma to the neck. He sustained a reconstructive operation on the traumatised section of the common carotid artery, which was replaced with an artificial Dacron-type prosthesis, despite additional anticoagulation therapy. During the autopsy, a thrombus was found adhered to the prosthesis-vessel transition. The macroscopical and histological examinations determined ischaemic brain stroke.These results imply that the carotid artery damage location is where the thrombus originated. It is therefore very likely that the thrombus formed as a result of an intimal tear in the carotid artery caused by the sharp force trauma. The patient died three days later, with clinical signs of coma and sudden respiratory and cardiac failure.

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In summary, for patients admitted for treatment as a result of neck trauma caused by a sharp object, it is important to monitor them, especially in the first few days, for the appearance of neurological symptoms [16]. It is known that in the early stages of development of an ischaemic stroke of the brain, changes may not be visualised with standard imaging techniques like a CT scan. Therefore, numerous tests have been developed that can provide an early evaluation of a neurological condition, such as the MMSE (mini mental state examination) or Folstein test, the Hodkin-son abbreviated mental test score. Highly sensitive imaging methods have also been developed, such as diffusion-weighted magnetic resonance imaging (DWI or DW-MRI), which is highly sensitive to the changes occurring in the lesion and revealing subclinical neurological changes. These imaging-specific methods could be used in combination with specific biochemical markers, proving the diagnosis [17]. CT angiography is also a highly sensitive and informative imaging method which could be in helpful use for the correct diagnosis.

Conclusion

Different diagnostic methods, clinical assessing tests and biochemical markers could be used in cases of sharp force neck trauma to diagnose this type of life-threatening post-traumatic complication in trauma patients. In each case of sharp or blunt neck trauma, the diagnosis “post-traumatic ischaemic brain stroke” must be ruled out as a possible serious complication. A detailed examination, including laboratory, ultrasonography, contrast angiography and various specific imaging methods with the rich patient’s history, periodic neurologic consultation and physical examination, must be performed as a standard algorithm for medical action in such types of clinical cases. That could prevent fatal complications and can save a patient’s life.

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*Corresponding author and requests for clarifications and further details:

Ivan Tsranchev,

Medical University of Plovdiv, Republic of Bulgaria, Europe

Email- tsranchev@inbox.ru