Carotid artery dissection and brain herniation following traditional carotid massage: a case report

Abstract

Carotid artery dissection is an important cause of ischemic stroke in young adults and has been associated with minor cervical trauma, including neck manipulation. Traditional carotid massage, commonly practiced in low-resource settings, is often perceived as harmless despite potential vascular risks. We report the case of an 18-year-old woman with no known comorbidities who developed acute neurological deterioration shortly after undergoing carotid massage by a traditional healer. Brain computed tomography revealed a large left hemispheric infarction involving the malignant middle cerebral artery territory, with associated cerebral edema, mass effect, and midline shift. Due to rapid clinical deterioration culminating in cardiac arrest and death within hours of presentation, advanced vascular imaging was not performed. Therefore, a diagnosis of carotid artery dissection was considered presumptive, based on clinical presentation and temporal association. The clinical course was further complicated by respiratory compromise and suspected pneumonia in the context of preceding fever, as well as hemodynamic instability. Although decompressive hemicraniectomy was recommended, surgical intervention was declined due to contextual and resource-related factors. This case highlights a severe ischemic stroke temporally associated with traditional carotid massage, while emphasizing the limitations in establishing causality in the absence of confirmatory vascular imaging. It underscores the need for cautious interpretation of such associations, increased public awareness regarding potentially harmful neck manipulation practices, and improved access to timely diagnostic and neurosurgical care in resource-limited settings.