Basilar Artery Occlusion Associated With Paradoxical Embolism After Traumatic Spinal Cord Injury: A Case Report

Basilar artery occlusion is a neurological emergency associated with high mortality and severe disability. In young patients without conventional vascular risk factors, identifying an uncommon embolic mechanism is essential for secondary stroke prevention. We report the case of a previously healthy 21-year-old man who sustained a 6-meter fall resulting in T9-T10 compression fractures with spinal canal compromise and complete traumatic spinal cord injury. He underwent posterior thoracic spinal instrumentation. During hospitalization, he developed sudden neurological deterioration characterized by a generalized tonic-clonic seizure, impaired consciousness, respiratory failure, and hemodynamic instability. Computed tomography angiography demonstrated a partial distal basilar artery occlusion without intracranial hemorrhage. Intravenous thrombolysis was contraindicated because of recent major trauma and spinal surgery. Mechanical thrombectomy using a direct aspiration technique achieved complete reperfusion (thrombolysis in cerebral infarction (TICI) scale 3). Transthoracic echocardiography with agitated saline demonstrated significant right-to-left shunting, with more than 30 microbubbles appearing in the left-sided cardiac chambers from the second cardiac cycle. Subsequent transesophageal echocardiography demonstrated a patent foramen ovale with increased interatrial septal mobility. Although deep venous thrombosis was not documented, the combination of severe spinal cord injury, prolonged immobilization, a prothrombotic state, and a patent foramen ovale with significant right-to-left shunting supported paradoxical embolism as the most plausible mechanism. This case highlights the importance of considering paradoxical embolism in young hospitalized patients who develop posterior circulation stroke following major trauma.