Abstract Introduction Blunt cerebrovascular injury (BCVI) requires prompt recognition and individualized hemodynamic management, particularly when coexisting with blunt cardiac or aortic injury. Blood pressure (BP) targets often diverge: permissive hypertension may be necessary to preserve cerebral perfusion in high-grade carotid dissection, while strict BP control reduces risk of aortic rupture. No clear algorithm exists to guide BP selection in patients with concurrent cerebral and cardiac injuries. We present a case demonstrating the role of non-invasive neuromonitoring with transcranial Doppler (TCD) to balance conflicting hemodynamic goals and mitigate secondary cerebral and vascular injury. Description A 27-year-old male presented after a high-speed motorcycle crash. Neurovascular imaging revealed BCVI with Biffl Grade IV right internal carotid artery (ICA) C1 segment occlusion, Grade II left ICA dissection, focal left vertebral artery dissection, and a small subdural hematoma. CT angiography of the chest demonstrated contrast extravasation at the aortic arch concerning for blunt cardiac/aortic injury. Standard management of aortic injury with strict systolic BP 100 mmHg conflicted with the higher pressures needed to maintain cerebral perfusion in high-grade BCVI. Bilateral TCD monitoring of middle cerebral artery mean flow velocities was used to dynamically titrate vasoactive medications in real time, individualizing BP targets to preserve cerebral blood flow while minimizing aortic wall stress. Follow-up transesophageal echocardiography and CT angiography demonstrated resolution of the blunt cardiac injury. The patient remained neurologically intact as BP goals were safely liberalized and was subsequently discharged to rehabilitation. Discussion This case highlights the clinical dilemma of simultaneous BCVI and blunt cardiac trauma, where conventional BP targets for one organ system may exacerbate injury in another. Continuous TCD monitoring provided real-time, non-invasive assessment of cerebral perfusion and enabled individualized hemodynamic management which contributed to secondary neurologic injury prevention without worsening the cardiac lesion. This case supports the utility of early neurovascular imaging, multidisciplinary coordination, and advanced neuromonitoring to reconcile competing management priorities in severe polytrauma. Continuous TCD monitoring has a role in guiding cerebral perfusion targets when standard hemodynamic algorithms conflict. This abstract is funded by: None
Ravichandran et al. (Fri,) studied this question.