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Background: Atraumatic localized convexity subarachnoid hemorrhage (cSAH) is an uncommon form of nonaneurysmal subarachnoid hemorrhage characterized by bleeding limited to the cerebral convexities. Ipsilateral cSAH can result from a variety of causes, such as internal carotid artery stenosis, obstruction, and dissection, although concomitant contralateral cSAH is exceptionally rare. In this case, the initial findings of cSAH led us to discovering contralateral internal carotid artery dissection (ICAD) and an elongated styloid process (ESP). ESP is recognized as a risk factor for ICAD, which is a hallmark of Eagle syndrome. This sequence of findings led to the diagnosis of Eagle syndrome, illustrating a complex and intriguing interplay between cerebrovascular conditions and anatomical variations., Case Presentation: A 47-year-old Japanese woman experienced acute onset of headache radiating to her neck, reaching its zenith approximately two hours after onset. Given the intractable nature of the headache and its persistence for three days, she presented to the emergency department. Neurological examination revealed no abnormalities, and the coagulation screening parameters were within normal ranges. Brain computed tomography (CT) revealed right parietal cSAH, while CT angiography (CTA) revealed ICAD and an ESP measuring 30.1 mm on the left side, positioned only 1.4 mm from the dissected artery. The unusual occurrence of contralateral cSAH prompted extensive and repeated imaging reviews that excluded reversible cerebral vasoconstriction syndrome (RCVS), leading to a diagnosis of left ICAD secondary to Eagle syndrome. The patient underwent conservative management, and the dissected ICA spontaneously resolved. The patient has remained recurrence-free for two and a half years., Conclusions: Managing cSAH requires diligent investigation for ICAD, extending beyond its identification to explore underlying causes. Recognizing Eagle syndrome, though rare, as a potential etiology of ICAD necessitates the importance of evaluating ESPs. The method for preventing recurrent cervical artery dissection due to Eagle syndrome is controversial; however, conservative management is a viable option., (© 2024. The Author(s).)

Background and Purpose: Cervical artery dissection (CAD) represents a leading cause of unilateral lower cranial nerve IX-XII palsy, known as Collet-Sicard syndrome (CSS). High-resolution magnetic resonance imaging (HR-MRI) is widely used in the evaluation of patients with CAD, providing information regarding vessel wall abnormalities and intraluminal thrombus., Methods: We present a patient with palsy of multiple lower cranial nerves in the context of CSS, attributed to unilateral spontaneous internal carotid artery dissection., Results: We describe a 68-year-old man with unremarkable previous history, who presented with subacute, gradually worsening dysphagia and hoarse voice. Clinical examination revealed right-sided palsy of cranial nerves IX-XII. Three-dimensional fat-saturated black-blood T1-weighted high-resolution vessel wall imaging disclosed spontaneous dissection with intramural hematoma along the distal right internal carotid artery. Neck MRI showed inward displacement of right aryepiglottic fold, right pyriform sinus dilatation, and right true vocal cord in middle position, indicative of right vagus nerve palsy, atrophy of right trapezius and sternocleidomastoid muscles, due to right spinal accessory nerve palsy, and unilateral tongue atrophy with fatty infiltration, characteristic for right hypoglossal nerve palsy., Conclusions: This case highlights the utility of high-resolution vessel wall imaging and especially fat-saturated T1-weighted black-blood SPACE (sampling perfection with application-optimized contrast using different flip-angle evolutions) sequences in the accurate diagnosis of CAD, revealing the characteristic mural hematoma and intimal flap. HR-MRI is also valuable in the recognition of indirect signs of lower cranial nerve compression., (© 2024 The Author(s). European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Purpose: To highlight the clinical and diagnostic importance of correctly identifying cervical internal carotid artery fenestration (fcICA), an extremely rare vascular anomaly, and to present a case where fcICA was initially misdiagnosed as a dissection in a patient with fibromuscular dysplasia (FMD)., Methods: A 47-year-old woman with pulsatile tinnitus underwent computed tomography angiography (CTA) and digital subtraction angiography (DSA) to differentiate between fenestration and dissection of the internal carotid artery., Results: CTA revealed a fusiform dilatation of the distal C1 segment of the right internal carotid artery (ICA) with a linear filling defect, suggesting either fenestration or dissection. DSA confirmed the presence of a fenestrated right ICA segment composed of two symmetrical, smooth-walled limbs without a dissection flap, along with signs of FMD in the proximal vessel. The patient's symptoms were attributed to local flow perturbations induced by fcICA and FMD., Conclusion: This case illustrates that fcICA can be a true anatomical variant rather than a result of dissection, emphasizing the need for accurate imaging and diagnosis to avoid unnecessary treatments. The coexistence of fcICA with FMD increases the risk of dissection, necessitating careful monitoring. The distinction between fenestration and pseudofenestration remains challenging, requiring comprehensive imaging and close collaboration between radiologists and vascular neurologists., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Carotid artery dissection is an important cause of stroke. However, the predictors of ischemic stroke in patients with carotid artery dissection are controversial. The study aimed to analyze the predictors of ischemic stroke in patients with carotid artery dissection through retrospective medical records., Methods: Data of discharged patients diagnosed with carotid artery dissection during 2019-2023 were retrospectively collected. Based on the occurrence of ischemic stroke, the patients were divided into the ischemic stroke or non-ischemic stroke groups. Based on the results of univariate analyses, variables with an associated P value < 0.05 were introduced into the multivariable logistic regression analysis. ., Results: A total of 165 patients were included in the study, with an average age of 55.00 (48.00, 66.00) years, including 86 patients with internal carotid artery dissection and 79 patients with vertebral artery dissection. Ischemic stroke occurred in 69 patients with carotid artery dissection. Multivariate logistic regression analysis indicated that diabetes (odds ratio [OR]: 3.144, 95% confidence interval [CI]: 1.552-6.508, P<0.002) and high white blood cells count (OR: 1.157, 95% CI: 1.02-1.327,P = 0.028) were related to the incidence of ischemic stroke in patients with carotid artery dissection., Conclusion: Ischemic stroke caused by carotid artery dissection causes severe damage to the nervous system. This study found that diabetes and high white blood cells count were associated with the incidence of ischemic stroke in patients with carotid artery dissection. Therefore, monitoring and controlling blood glucose levels and infections is essential in patients with carotid artery dissection to reduce the incidence of stroke., (© 2024. The Author(s).)

A man in his 50s presented with acute left-sided weakness, facial drooping and slurred speech, suggestive of a major stroke. Imaging revealed a complete blockage in the right internal carotid artery (ICA) due to dissection. Perfusion studies showed a significant area at risk of infarction. Attempted navigation of standard carotid stents failed due to the tortuosity of the ICA. A balloon-mounted coronary stent was successfully deployed in the petrous ICA segment, restoring blood flow. A follow-up MRI confirmed stent patency, and the patient achieved complete recovery with return to baseline function. Symptomatic carotid artery dissections can be treated with stenting to prevent strokes, however, tortuous ICAs in distal dissections pose a technical challenge. Balloon-mounted coronary stents, though not approved for this use, can offer a feasible solution. This case highlights the need for further research and development of devices for managing dissections in distal locations in tortuous ICAs., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Agenesis or hypoplasia of the internal carotid artery (ICA) may easily be confused with dissection or occlusion. We report a case of a 24-year-old female with complaint of acute left-hand hypoesthesia and a history of occasional intermittent numbness of her right hand with myoclonic jerking. Because previous imaging studies over 2 years were interpreted as occlusion of the left ICA secondary to carotid dissection, the treating physician had prescribed anticoagulant therapy. During transcranial Doppler (TCD) examination, the spectral waveform was unexpectedly normal, prompting a repeat review of all imaging due to the TCD results. Magnetic resonance angiography (MRA) revealed the same "flame-like" appearance of the ICA origin. Late-phase digital subtraction angiography showed a small caliber cervical ICA (occluded at the skull base). Computed tomography demonstrated absence of the carotid canal, confirming an absent intracranial portion of the ICA and establishing a correct diagnosis of left internal carotid hypoplasia. Vascular ultrasound and TCD examinations are noninvasive and inexpensive tools that can improve the interpretation and understanding of the clinical significance of other "static" radiographic tests (MRA, digital subtraction angiography ). An accurate diagnosis is essential to avoid risky, aggressive treatment, such as anticoagulation for an "absent" dissection., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2024 The Author(s).)

Clinical Issue: Craniocervical dissections are among the most common causes of stroke in people aged under 50 years, which is why it is essential to clarify, diagnose, and treat them as quickly as possible. Dissections usually occur spontaneously due to bleeding into the vessel wall. The affected segments are usually the motion segments of the internal cerebral artery (C1 segment) and the vertebral artery (V3 segment). Clinically, there is head and/or neck pain and neurologic symptoms, which can vary according to the localization of the dissection., Practical Recommendations: Pathognomonic is the detection of an intramural hematoma due to bleeding into the vessel wall. This can best be detected by magnetic resonance imaging (MRI) in native, fat-saturated T1 sequences (black-blood sequence). In addition, contrast-enhanced angiography should be performed using MRI or, alternatively, computed tomography (CT). As there is an increased risk of embolic or hemodynamically induced strokes, prophylactic treatment should be initiated immediately; it remains a case-by-case decision whether antiplatelet agents or oral anticoagulants are chosen for this purpose., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Hyoid bone-related carotid injury is a rare cause of neurovascular events. This report describes a case of a young, healthy male presenting with neck pain followed by left-sided hemiparesis. The patient was diagnosed with a transient ischaemic attack attributed to structural damage of the vascular surface of the right internal carotid artery as a direct result of continuous compression by an elongated hyoid bone. We describe a successful diagnosis using a series of manoeuvres during a six-vessel cerebral angiogram. Genetic testing later confirmed the diagnosis of vascular Ehlers-Danlos syndrome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose: The value of long-term serial imaging of dissecting pseudoaneurysm (dPSA) is poorly characterized. This study investigated the long-term radiographic evolution of dPSA., Methods: We performed a query in our institutional craniocervical artery dissection registry to identify cases with spontaneous dPSA who had at least one year of follow-up with serial angiographic imaging. We performed Wilcoxon rank-sum pairwise comparison test to determine if there was a significant change in the aneurysm size over time., Results: This observational cohort study included 76 patients (46 females; 64 dPSA in the internal carotid artery [ICA] and 12 in the vertebral artery [VA]) with a median age of 49.5 years (range 24-77). The initial median dPSA size was 8 mm (interquantile range(iqr) = 5.88-11mm), and the final median dPSA size was 7 mm (iqr = 4-11 mm). Most patients had either no change or reduction in dPSA size in the serial follow-up, with no significant change over time. All the patients had favorable outcomes at the last follow-up, and most patients were symptom-free from dPSA (92 %). Two patients (2.6%) experienced recurrent ischemic strokes in the same territory as the initial ischemic stroke without any change in dPSA size., Conclusion: Further serial scans for dPSA after one year may be deferred in the absence of interim clinical symptoms as most dPSA either remains stable or decreases in size. Recurrent stroke, although a rare event, was not associated with an increase in dPSA size., Competing Interests: Declaration of competing interest The authors declare no relevant interests for this study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Spontaneous cervical artery dissection, a nontraumatic tear in the wall of an internal carotid or vertebral artery, is a common cause of stroke, particularly in patients younger than 40 years of age; however, petrous internal carotid artery dissection is extremely rare. This case report describes a 50-year-old woman who had a spontaneous intrapetrous internal carotid dissection thought to be secondary to active SARS-CoV-2 infection; the dissection was treated successfully with a flow-diverter stent., (© 2024 The Authors. Published by The Texas Heart Institute®.)

Competing Interests: Competing interests: None declared.

Background: Small, randomized trials of patients with cervical artery dissection showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with cervical artery dissection treated with antiplatelets versus anticoagulation., Methods: This is a multicenter observational retrospective international study (16 countries, 63 sites) that included patients with cervical artery dissection without major trauma. The exposure was antithrombotic treatment type (anticoagulation versus antiplatelets), and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with inverse probability of treatment weighting to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an as-treated crossover approach and only included outcomes occurring with the above treatments., Results: The study included 3636 patients (402 [11.1%] received exclusively anticoagulation and 2453 [67.5%] received exclusively antiplatelets). By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with inverse probability of treatment weighting, compared with antiplatelet therapy, anticoagulation was associated with a nonsignificantly lower risk of subsequent ischemic stroke by day 30 (adjusted hazard ratio [HR], 0.71 [95% CI, 0.45-1.12]; P =0.145) and by day 180 (adjusted HR, 0.80 [95% CI, 0.28-2.24]; P =0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR, 1.39 [95% CI, 0.35-5.45]; P =0.637) but was by day 180 (adjusted HR, 5.56 [95% CI, 1.53-20.13]; P =0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR, 0.40 [95% CI, 0.18-0.88]; P interaction =0.009)., Conclusions: Our study does not rule out the benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings., Competing Interests: Disclosures Disclosures provided by Dr Nguyen in compliance with American Heart Association annual Journal Editor Disclosure Questionnaire are available at https://www.ahajournals.org/editor-coi-disclosures. Dr Arnold reports compensation from Boehringer Ingelheim, AstraZeneca, Bayer, Bristol-Myers Squibb, Covidien, Daiichi Sankyo, Novartis, Sanofi, Pfizer, Medtronic, Novo Nordisk, and Amgen for consultant services. Dr Lester reports a provisional patent for Methods and compositions for disrupting tau aggregates. Dr Touze reports compensation from Elsevier for other services and employment by Caen. J.E. Kaufman reports grants from Goldschmidt Jacobson-Stiftung. Dr Traenka reports travel support from Bayer Healthcare. Dr Aguiar de Sousa reports compensation from Daiichi Sankyo, Bayer, AstraZeneca, Johnson & Johnson, and Fundação Bial for other services; compensation from the University of British Columbia for data and safety monitoring services; compensation from Organon & Co for consultant services. Dr Rosa reports grants from Merck Sharp & Dohme Corporation. Dr Field reports compensation from HLS Therapeutics, AstraZeneca Canada, and Roche for consultant services; service as a board member for Destine Health; and compensation from the Canadian Medical Protective Association for expert witness services; and grants from Bayer. Dr Leker reports compensation from Medtronic, Ischemaview, Bayer, Abbott Diabetes Care, Biogen, Janssen Biotech, and Boehringer Ingelheim for other services. Dr Nolte reports compensation from Daiichi Sankyo Europe GmbH, Boehringer Ingelheim, Pfizer, Bristol-Myers Squibb, and Alexion Pharmaceuticals for consultant services; and compensation from AstraZeneca, Abbott Canada, Deutsches Zentrum für Neurodegenerative Erkrankungen, Novartis, Portola Pharmaceuticals, Deutsches Zentrum für Herz-Kreislaufforschung, and Novartis for other services. Dr Poppe reports grants from Foundation Brain Canada, Heart and Stroke Foundation of Canada, and Stryker; and compensation from Roche for other services. Dr Liebeskind reports compensation from Medtronic, Genentech, Cerenovus, Stryker, and Rapid Medical Ltd, for consultant services. B. Mac Grory reports grants from the National Institutes of Health; employment by Duke University Medical Center; compensation from Bayer for other services; grants from the American Heart Association, Duke Bass Connections, and the Duke Office of Physician Scientist Development. Dr Al Kasab reports compensation from Stryker for other services and employment by Medical University of South Carolina. Dr Kicielinski reports compensation from Stryker, Penumbra Inc, Medtronic, and MicroVention Inc, for other services; travel support from MicroVention Inc; and employment by Medical University of South Carolina and Elsevier. Dr de Havenon reports stock options in TitinKM and Certus; grants from the National Institutes of Health; and compensation from Novo Nordisk for consultant services. Dr Siegler reports grants from Philips and employment by the University of Chicago. Dr Willey reports compensation from Edwards Lifesciences Corporation and Abbott Fund for end point review committee services; compensation from Uptodate for other services; and compensation from the Abbott Laboratories for consultant services. Dr Sharma reports a provisional patent for a stroke etiology classifier algorithm and grants from the National Institutes of Health Clinical Center. Dr Martins reports compensation from Pfizer, Medtronic, Servier Affaires Medicales, Daiichi Sankyo, Bayer, Novo Nordisk, Novartis, Penumbra Inc, and Boehringer Ingelheim for other services. Dr Simpkins reports grants from the National Institutes of Health. Dr Stretz reports grants from Massachusetts General Hospital. Dr Furie reports compensation from Janssen Biotech for consultant services. The other authors report no conflicts

Background: Isolated traumatic supraclinoid internal carotid artery (ICA) dissection is a rare complication of blunt craniomaxillofacial trauma, and differentiation from atherosclerosis is the key factor for confirming the diagnosis., Case Description: A 53-year-old man was admitted because of blunt trauma to his head and face. His primary manifestations were disability of abduction of the left eye on day 2, recurrent epistaxis and a blowing murmur in the left ear on day 4. Neurological physical examination showed bilateral normal pupil diameter, a corrected visual acuity of 0.6 in the right eye and 0.3 in the left eye, and loss of abduction of the left eye. Craniofacial computed tomography scans revealed multiple craniomaxillofacial fractures mainly including a LeFort III injury of the left maxilla, fractures of the left ramus of the mandible, fractures of the left orbital apex, fractures of the sellar turcica, etc. Brain magnetic resonance (MR) findings showed multifocal lacunar infarcts in the left hemisphere. Cerebral angiography demonstrated severe intraluminal stenosis of the left supraclinoid ICA, which was highly suspicious of arterial dissection. A high-resolution vessel wall MR imaging performed on day 7 showed proximal intramural subacute haemorrhage and two distal intimal flaps at the injured region, both of which facilitated the exclusion of atherosclerosis and thus, confirmation of isolated arterial dissection. The patient underwent treatment with endovascular stent placement and antiplatelet agents two weeks later and had no ictus of symptomatic stroke during the next half-year duration., Conclusions: HR vw-MRI is able to assist in the diagnosis of isolated traumatic supraclinoid dissection complicated with underlying atherosclerosis.

We report the case of a young woman affected by an aneurysmal subarachnoid haemorrhage (SAH) and numerous anatomic abnormalities. A Transcranial Colour-Coded Duplex Sonography, performed with the aim of monitoring the vasospasm, showed a non-pulsatile flow with loss of sharp systolic peak and lowering of mean flow velocities in the right extracranial Internal Carotid Artery (ICA) and all its intra-cranial branches. This event suggested a possible concomitant acute right ICA sub-occlusion with a lack of collateral circulation. This type of flow is typically found in systemic and brain arteries of patients undergoing to venous-arterial extracorporeal membrane oxygenation or to left ventricular assist devices. The absence of an adequate cerebral collateral circulation might be the explanation for this type of atypical flow. Aneurysms and arterial dissections contribute to SAH and ischemic stroke events, leading to long-term physical and cognitive disability. In our case, the prompt neurosonological diagnosis leaded to patient's good outcome., (© 2022. Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).)

Introduction: Cervical artery dissections (CAD) are the leading cause of ischemic stroke (CVA) in young people. The risk factors for stroke and the temporal relationship with CAD are not well characterized. Nor do we have a clinical-radiological classification that allows knowing the risk of stroke., Objective: To describe the associated factors and temporality of ACVi in patients with CAD., Methods: We performed a prospective study that included patients over 18 years of age, hospitalized for carotid and/or vertebral CAD between August 2009 and June 2017. CAD cases were diagnosed clinically and radiologically; ACVi was diagnosed when the imaging study demonstrated infarction. The Borgess Classification was used to characterize the CAD radiologically. For correlation studies, we used univariate and multivariate logistic regression analyses., Results: We analyzed 163 patients with 182 CAD (60% vertebral and 40% carotid). 28 of 68 patients (41.2%) simultaneously had symptoms of dissection and ischemia. 60 of 68 patients (88%) presented symptoms of ischemia during the first week. CAD: Borgess type IB (p = 0.001; OR: 4.1; CI: 1.8-9.3), male (p < 0.001; OR: 0.2; CI: 0.06- 0.8) were significantly associated with ischemic strokes and oral contraceptives (p = 0.02; OR: 0.2; CI: 0.06-0.8)., Conclusion: Stroke associated with CAD has a relatively low frequency. It is not related to the type of dissected artery. It mainly occurs not simultaneously with CAD and within the first week. The main associated factor for developing a stroke is arterial occlusion (Borgess type IB).1,8-9,3), male sex (p < 0.001; OR: 0.2; CI: 0.06-0.8) and oral contraceptives (p = 0.02; OR: 0.2; CI: 0.06-0.8).

Background: Spontaneous cervical artery dissection (sCAD) is a leading cause of ischemic stroke in young patients. Studies using high-resolution magnetic resonance imaging and positron emission tomography have suggested vessel wall inflammation to be a pathogenic factor in sCAD. Computed tomography (CT) attenuation of perivascular adipose tissue (PVAT) is an established non-invasive imaging biomarker of inflammation in coronary arteries, with higher attenuation values reflecting a greater degree of vascular inflammation., Objectives: We evaluate the CT attenuation of PVAT surrounding the internal carotid artery (PVAT carotid ) with and without spontaneous dissection., Methods: Single-center prospective observational study of 56 consecutive patients with CT-verified spontaneous dissection of the internal carotid artery (ICA). Of these patients, six underwent follow-up computed tomography angiography (CTA). Twenty-two patients who underwent CTA for acute neurological symptoms but did not have dissection formed the control group. Using semi-automated research software, PVAT carotid was measured as the mean Hounsfield unit (HU) attenuation of adipose tissue within a defined volume of interest surrounding the ICA., Results: PVAT carotid was significantly higher around dissected ICA compared with non-dissected contralateral ICA in the same patients (-58.7 ± 10.2 vs -68.9 ± 8.1 HU, p  < 0.0001) and ICA of patients without dissection (-58.7 ± 10.2 vs -69.3 ± 9.3 HU, p  < 0.0001). After a median follow-up of 89 days, there was a significant reduction in PVAT carotid around dissected ICA (-57.5 ± 13.4 to -74.3 ± 10.5 HU, p  < 0.05), while no change was observed around non-dissected contralateral ICA (-71.0 ± 4.4 to -74.1 ± 4.1 HU, p  = 0.19). ICA dissection was an independent predictor of PVAT carotid following multivariable adjustment for age and the presence of ICA occlusion., Conclusion: PVAT carotid is elevated in the presence of sCAD and may decrease following the acute event.

Objective: The aim of the study is to evaluate the natural history of extracranial cervical artery dissection (CAD) including comorbidities, symptoms at presentation, recurrence of symptoms, and long-term outcome following different treatment approaches., Methods: A retrospective review of patients treated for acute CAD was performed over a 5-year period from January 2017 to April 2022., Results: Thirty-nine patients were included in the study, 25 (64.1%) with acute internal carotid artery dissection and 14 (35.9%) with acute vertebral artery dissection. Thirty-four patients (87.1%) had spontaneous CAD, and five patients (12.8%) had traumatic CAD. The mean age of the cohort was 54.2 years. The mean time from symptom onset to presentation was 4.34 days. The most common symptoms in internal carotid artery dissection were unilateral weakness (44%), headache (44%), slurred speech (36%), facial droop (28%), unilateral paraesthesia (24%), neck pain (12%), visual disturbance (8%), and Horner's syndrome (8%). The most common symptoms in vertebral artery dissection were headache (35.7%), neck pain (35.7%), vertigo (28.57%), ataxia (14.28%), and slurred speech (14.28%). The imaging modalities used for diagnosis included computed tomography angiography (48.7%), magnetic resonance angiography (41%), and duplex ultrasound (10.2%). In patients with carotid artery dissection, 57% had severe stenosis, 24% had moderate stenosis, and 20% had mild stenosis. All patients treated were managed conservatively with either anticoagulation or antiplatelets. Long-term clinical follow-up was available for 33 patients (84.6%). Thirty patients (90.9%) reported complete resolution of symptoms, and three patients (9%) reported persistent symptoms. Anatomic follow-up with imaging was available for 17 patients (43.58%). Thirteen patients (76.47%) had complete resolution of dissection, two patients (11.76%) had partial resolution of dissection, and two patients (11.76%) had persistent dissection. There was one death unrelated to CAD in a multi-trauma patient. There were four early recurrent symptoms in the first 3 to 8 weeks post discharge. The mean follow-up time was 308.27 days., Conclusions: The majority of CADs can be managed conservatively with good clinical and anatomical outcome and low rates of recurrence., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Carotid artery dissection (CAD) is a common cause of stroke, accounting for up to 25% of all ischemic strokes in young and middle-aged patients. CAD should be considered in young patients with unexplained head and neck pain, with or without focal neurological symptoms and signs. While the clinical features may raise suspicion for CAD, the diagnosis is confirmed by its typical neuroimaging findings. Meanwhile, simultaneous spontaneous dissection of the bilateral carotid artery has rarely been reported. We herein describe a clinically challenging case of a simultaneous bilateral CAD that was successfully treated with bilateral carotid artery stenting (CAS). The patient recovered satisfactorily after completing the whole course of treatment. Keywords: Acute stroke, Bilateral Spontaneous carotid artery dissection, Endovascular treatment.

Spontaneous cervical artery dissection (sCeAD) is the most common cause of ischemic stroke at a young age, but its pathogenetic mechanism and risk factors are not fully elucidated. It is reasonable to think that bleeding propensity, vascular risk factors such as hypertension and head or neck trauma, and constitutional weakness of the arterial wall together play a role in the pathogenesis of sCeAD. Hemophilia A is known to be an X-linked condition that leads to spontaneous bleeding in various tissues and organs. To date, a few cases of acute arterial dissection in patients with hemophilia have been reported, but the relationship between these two diseases has not been studied so far. In addition, there are no guidelines indicating the best antithrombotic treatment option in these patients. We report the case of a man with hemophilia A who developed sCeAD and transient oculo-pyramidal syndrome and was treated with acetylsalicylic acid. We also review previous published cases of arterial dissection in patients with hemophilia, discussing the potential pathogenetic mechanism underlying this rare association and potential antithrombotic therapeutic options., (© 2023. Fondazione Società Italiana di Neurologia.)

This is a case report of a 38-year-old, previously healthy man who was initially seen at an otorhinolaryngological department due to "swelling" of his tongue. Further history revealed four days of severe, non-specific headache and lisping. Two weeks prior to hospital admission he had seen a chiropractor due to neck pain. On examination at the hospital there was isolated left hypoglossal nerve palsy. He was urgently referred to a department of neurology. Magnetic resonance angiography showed internal carotid artery dissection. Aspirin and clopidogrel were commenced. At the three months follow-up examination he had recovered completely symptom wise and a renewed magnetic resonance imaging was normal.

Craniocervical dissection is one of the most common causes of stroke in children. Although the most common cause of dissection is trauma, spontaneous dissections in which no cause can be revealed may also occur. The diagnosis of this type of dissection in children can be challenging with the preferred non-invasive imaging methods (MRA, CTA). Intracranial vessel wall imaging is a promising novel method for identifying specific signs of dissection. We report an 11-year-old girl with spontaneous ICA dissection, whose diagnosis was confirmed by an MRI of the intracranial vessel wall. Vessel wall imaging has contributed substantially to the diagnosis and follow-up of this case., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Internal carotid artery dissection (ICAD) is a rare cause of acute ischemic stroke with large vessel occlusion (AIS-LVO). We aimed investigating the impact on outcome of internal carotid artery (ICA) patency after mechanical thrombectomy (MT) for AIS-LVO due to occlusive ICAD., Patients and Methods: We included consecutive patients with AIS-LVO due to occlusive ICAD treated with MT from January 2015 to December 2020 in three European stroke centers. We excluded patients with unsuccessful intracranial reperfusion after MT (modified Thrombolysis in Cerebral Infarction (mTICI) score < 2b). We compared 3-month favorable clinical outcome rate, defined as a modified Rankin scale (mRS) score ⩽2, according to ICA status (patency vs occlusion) at the end of MT and at 24-h follow-up imaging, using univariate and multivariable models., Results: Among 70 included patients, ICA was patent in 54/70 (77%) at the end of MT, and in 36/66 (54.5%) patients with 24-h follow-up imaging. Among patients with ICA patency at the end of MT, 32% presented ICA occlusion at 24-h control imaging. Favorable 3-month outcome occurred in 41/54 (76%) patients with ICA patency post-MT and in 9/16 (56%) patients with occluded ICA post-MT ( p  = 0.21). Rates of favorable outcome were significantly higher in patients with 24-h ICA patency compared to patients with 24-h ICA occlusion (32/36 [89%] vs 15/30 [50%]), with an adjusted odds ratio of 4.67 (95% CI: 1.26-17.25)., Discussion and Conclusion: Obtaining sustained (24-h) ICA patency after MT could be a therapeutic target for improving functional outcome in patients with AIS-LVO due to ICAD., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© European Stroke Organisation 2022.)

Intracranial carotid artery dissection causing cerebral ischemia is a rare but important cause of cerebral infarction in children and adolescents. Although endovascular therapy has been reported to be effective, questions regarding the indications for intervention are yet to be addressed. Therefore, this study aimed to evaluate factors related to clinical outcomes through a nationwide survey. Overall, 35 neurosurgical centers reported patients within 2 weeks after ischemic onset due to intracranial carotid artery dissection causing cerebral ischemia treated between January 2015 and December 2020. Data on clinical and radiological findings were statistically analyzed. Twenty-eight patients met the inclusion criteria. The median age was 36 years (range, 7-59 years), without sex differences. Headache at onset was documented in 60.7% of the patients. Dissection findings were categorized into stenosis (71.4%) or occlusion (28.6%). Initial treatments, including various antithrombotic agent combinations in 23 (82.1%) patients, effectively improved or prevented aggravation in half of the patients. The patients with stenotic dissection were significantly more likely to experience aggravation during the initial treatment than did those with occlusive dissection (P = 0.03). In addition, the patients with moderate to severe neurological deficits on admission had poorer outcomes at discharge more frequently than did those with mild neurological deficits on admission. Eight patients undergoing endovascular therapy had no procedural complications or further aggravation after intervention. In conclusion, patients with intracranial carotid dissection causing cerebral ischemia who had a stenotic dissection were at risk of further aggravation, and endovascular therapy effectively improved or prevented aggravation.

Background: The optimal management of patients with acute ischemic stroke (AIS) due to tandem occlusion (TO) and underlying carotid dissection (CD) remains unclear., Objective: We present our multicenter-experience of endovascular treatment (EVT) approach used and outcomes for AIS patients with CD-related TO (CD-TO)., Methods: Consecutive AIS patients underwent EVT for CD-TO at five Italian Neuro-interventional Tertiary Stroke Centers were retrospectively identified. TO from atherosclerosis and other causes of, were excluded from the final analysis. Primary outcome was successful (mTICI 2b-3) and complete reperfusion (mTICI 3); secondary outcome was patients' 3-months functional independence (mRS≤2)., Results: Among 214 AIS patients with TO, 45 presented CD-TO. Median age was 54 years (range 29-86), 82.2% were male. Age <65 years ( p < 0.0001), lower baseline NIHSS score ( p = 0.0002), and complete circle of Willis ( p = 0.0422) were associated with mRS ≤ 2 at the multivariate analysis. Comparisons between antegrade and retrograde approaches resulted in differences for baseline NIHSS scores ( p = 0.001) and number of EVT attempts per-procedure ( p = 0.001). No differences in terms of recanalization rates were observed between antegrade and retrograde EVT approaches ( p = 0.811) but higher rates of mTICI3 revascularization was observed with the retrograde compared to the antegrade approach (78.6% vs 73.3%), anyway not statistically significant. CD management technique (angioplasty vs aspiration vs emergent stenting) did not correlate with 3-months mRS≤2., Conclusion: AIS patients with CD-TO were mostly treated with the retrograde approach with lower number of attempts per-procedure but it offered similar recanalization rates compared with the antegrade approach. Emergent carotid artery stenting (CAS) proved to be safe for CD management but it does not influence 3-months patients' clinical outcomes.

Objective: Eagle syndrome or styloid process syndrome is a clinical condition of complex aetiology. Since, as a consequence of vascular compression,due to the length of the styloid process and its nearness to the internal carotid artery,it can lead to vertigo. Vertigo may be the only symptom of stylocarotid syndrome and it is extremely challenging diagnose.To the best of our knowledge, this is the first study that measures the lengths of styloid process on the Croatian population's,and possible influence of styloid process length on isolated vertigo of unknown aetiology., Methods: This study included 829 subjects who were divided into two groups.The first group was the control group, consisting of 800 subjects.The second group, study group, consisted of 29 subjects who suffered from the vertigo of unknown aetiology., Results: The statistically significant difference between the study and the control group was observed in the length of the styloid process, and in the closest distance of the styloid process from the carotid artery., Conclusions: The prolonged styloid process and its close association with the internal carotid artery may affect vertigo of unknown aetiology and should be clinically and radiographically investigated in cases of unexplained vertigo as an isolated and only symptom within stylocarotid syndrome., Competing Interests: Competing interests None declared., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: To study the ischemic stroke risk factors in spontaneous internal carotid artery dissection (ICAD) patients via analyzing the dissection features and primary collateral circulation using vessel wall-MRI and magnetic resonance angiography., Methods: ICAD patients who had undergone VW-MRI were included in this study. A total of 36 patients were included and divided into ICAD stroke ( N = 23) and non-stroke ( N = 13) group. Dissection imaging features [intramural hematoma (IMH), length of IMH, intimal flap, double lumen, intraluminal thrombus, degree of stenosis] and primary collateral status were analyzed. The primary collateral score (0-4) was evaluated based on presence of anterior communicating and ipsilateral anterior cerebral artery A1 segment (0-2) and ipsilateral posterior communicating artery (0-2)., Results: There were no significant differences in dissection imaging features such as presence of double lumen, intimal flap, IMH, length of IMH and intraluminal thrombus between the two groups. Degree of stenosis and primary collateral score showed significant differences between the two groups., Conclusion: Both the poor primary collateral circulation and severe stenosis may play an important role in occurrence of ischemic stroke for spontaneous ICAD patients and good primary collateral circulation can help to reduce the incidence of infarction., Advances in Knowledge: ICAD is one of the major causes of ischemic stroke. Early evaluation of the status of the Circle of Willis in ICAD patients by MRI may help to make treatment strategies and improve clinical outcome.

Background and Aims: Cervical artery dissection (CAD) is an infrequent but potentially disabling and fatal disease, accounting for up to 25 % of strokes in young adults. Pregnancy-related hormonal changes and increased hemodynamic stress on artery walls during vaginal delivery have been associated to CAD. We aim to describe a series of women presenting CAD during postpartum (PP) after cesarean and vaginal delivery., Methods: CAD women admitted to one hospital in Santiago, Chile, between July 2018 and October 2020 were included in a prospective cohort. Demographic, clinical and imaging data were registered for the PP group., Results: Sixty-seven women were diagnosed with CAD, from which 10 were PP. Seven women had cesarean section and 3 had vaginal delivery. They presented CAD related symptoms after a median of 10.5 (IQR 5-15) days from delivery. All of them had headache as initial symptom, 9 presented cervical pain and 8 had a family history of stroke. Four patients presented preeclampsia during pregnancy. Acute treatment consisted mostly in antiplatelet agents and analgesics. None of these patients had a CAD related stroke. Demographic, clinical and imaging characteristics of these women with CAD during PP are described., Conclusions: This case series underpins the importance of clinical suspicion of CAD after delivery, highlighting the fact that CAD is not limited to women with vaginal delivery, thus alternative causes beyond acute hemodynamic stress could be involved. Further research is required to determine genetic components, along with deeper knowledge of modulating factors related to CAD in this setting., Competing Interests: Declaration of Competing Interest EM and AS report no conflicts of interest regarding this study, (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Head/neck pain is one of the primary symptoms associated with spontaneous cervical artery dissection. Still, data on pain quality, intensity, and long-term dynamics are scarce., Methods: Spontaneous cervical artery dissection subjects were included if mural hematoma was visualised through T1 fat-saturated MRI at baseline. All available medical records were evaluated and patients were invited to standardised clinical follow-up visits at least 1 year after the index event., Results: In total, 279 subjects were included in the ReSect-study with head/neck pain being the most frequent symptom of spontaneous cervical artery dissection (220 of 273, 80.6%). Pain was of pulling nature in 107 of 218 (49.1%), and extended to the neck area in 145 of 218 (66.5%). In those with prior headache history, pain was novel in quality in 75.4% (42 of 55). Median patient-reported pain intensity was 5 out of 10 with thunderclap-type headache being uncommon (12 of 218, 5.5%). Prior to hospital admission, head/neck pain rarely responded to self-medication (32 of 218, 14.7%). Characteristics did not differ between subjects with and without cerebral ischemia. Pain resolved completely in all subjects within a median of 13.5 days (IQR 12). Upon follow-up in 42 of 164 (25.6%) novel recurring headache occurred, heterogeneous in quality, localisation and intensity., Conclusion: We present an in-depth analysis of spontaneous cervical artery dissection-related head/neck pain characteristics and its long-term dynamics.

Background: Strangulation as a fight-finishing maneuver in combat sports, termed "choking" in that context, occurs worldwide millions of times yearly. This activity can be trained safely, but devastating injuries can occur., Objective: Our aim was to present a case series of cervical artery dissections and ischemic strokes associated with sportive choking. Sharing these cases is meant to draw awareness, to assist emergency physicians in caring for these athletes, and to provide a platform for further research., Methods: Institutional Review Board approval was obtained. Participants consented for medical information transfer and anonymous academic reproduction. The minimum medical record information necessary for inclusion was a report of diagnosis-confirming advanced imaging. Participants were contacted for primary information in addition to what the medical records could provide and to confirm some information in the record (e.g., pertinent medical history, demographic characteristics, choking event description, medical care, and commentary on their current health). Medical records and additional first-hand information were reviewed and participants were included if they had a diagnosed dissection or stroke likely associated with a sportive choke., Results: Ten cases met all criteria for inclusion. There were 5 cases of carotid artery dissection, 3 cases of vertebral artery dissection, and 2 cases of ischemic stroke without dissection. Nine of 10 participants survived and 3 of 10 have returned to submission grappling training., Conclusions: Cervical artery dissections and ischemic strokes can occur in association with sportive choking. Emergency physicians must be aware of the widespread nature of this activity and must be vigilant in approaching management of patients with symptoms consistent with these injuries., (Copyright © 2022. Published by Elsevier Inc.)

Objectives: Ischemic stroke is the most common presentation of cervical artery dissection (CAD). Information regarding CAD-induced stroke is scarce, especially in the Middle East. Here we investigated the incidence of CAD-induced stroke, its characteristics, and the clinical course in central Iran., Methods: This is an observational study conducted in the city of Isfahan, Iran. We recruited patients with ischemic stroke during 2017-2019. We analyzed characteristics of the CAD-induced stroke patients with regards to the involved vessel (internal carotid artery dissection (ICAD) or vertebral artery dissection (VAD)). We assessed functional outcome (modified Rankin Scale [mRS]) and recanalization status after 1 year of follow-up., Results: Among 3630 ischemic stroke patients, 51(1.4%) had CAD-induced stroke (mean age: 41.8 ± 12.6; 40.4% female; 28 and 19 ICAD and VAD cases, respectively). The crude incidence rate of CAD-induced stroke was 1.20/100,000/year (0.66/100,000/year and 0.45/100,000/year for strokes due to ICAD and VAD, respectively). mRS ≤ 2 was present in 63.8% of the patients after 1 year of follow-up. History of exercise during the last days before stroke occurrence was associated with a better follow-up mRS (β = -3.1, p-value: 0.037). Administration of anticoagulant or double-antiplatelets was related neither to mRS nor recanalization results. Trauma (27.7%), smoking (21.3%), and headache disorders/migraine (21.3%) were the most common reported factors., Conclusion: We found a crude incidence rate of 1.20/100,000/year for CAD-induced stroke. Trauma, smoking, and headache disorders were the most common reported factors among our patients. CAD-induced stroke had a favorable long-term prognosis regardless of the type of the involved vessel or the used medication., (© 2022. The Author(s).)

Objective: Endovascular treatment of cervical internal carotid artery (ICA) loop dissections in acute stroke interventions can be challenging. Flow diverters can effectively reconstruct vessel loops and treat the injured vessel and provide a safe conduit for intracranial catheterization., Methods: We retrospectively reviewed our neurointerventional database and identified all patients with ICA loop dissections treated with flow diverters in the acute setting between August 2016 and September 2020. Patient demographics, procedural data, imaging follow-up results, and clinical outcome information were collected., Results: Seven patients with a mean age of 62 years (range: 43-85 years) who underwent reconstruction of an ICA (loop) dissection with flow diverters were included. Four ICA dissections were treated with the Surpass Streamline flow diverter and 3 with the Pipeline embolization device. All cases were technically successful. All stroke cases achieved intracranial flow ≥thrombolysis in cerebral infarction 2B. Observed intracranial hemorrhages were all asymptomatic. All cases showed patent flow diverter(s) with or without (carotid) stent(s) on follow-up imaging. Semielectively treated patients did not show a change from baseline modified Rankin scale related to the procedure. Patients with acute stroke had a modified Rankin scale ≤2 in 4 of 5 cases (80%) at 3 months. Two patients died due to medical issues unrelated to the procedures. No patient showed new or recurrent symptoms., Conclusion: Use of flow diverters, in some cases in conjunction with (carotid) stents, is an effective treatment option for cervical carotid artery (loop) dissections., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Craniocervical artery dissection (CAD), although uncommon, can affect the young and lead to devastating complications, including stroke and subarachnoid hemorrhage. It starts with a tear in the intima of a vessel with subsequent formation of an intramural hematoma. Most CAD occurs spontaneously or after minor trauma. Patients with CAD may exhibit isolated symptoms of an underlying subclinical connective tissue disorder or have a clinically diagnosed connective tissue disorder. Emergent evaluation and computed tomography angiography or magnetic resonance imaging/angiography of the head and neck are required to screen for and to diagnose CAD. Carotid ultrasound is not recommended as an initial test because of limited anatomic windows; diagnostic catheter-based angiography is reserved for atypical cases or acutely if severe neurologic deficits are present. Patients with CAD can present with focal neurologic deficits due to ischemia (thromboembolism or arterial occlusion) or subarachnoid hemorrhage (pseudoaneurysm formation and rupture). Also common are local symptoms, such as head and neck pain, pulsatile tinnitus, Horner syndrome, and cranial neuropathy, or cervical radiculopathy from mass effect. Acute management of transient ischemic attack/stroke in CAD is not different from the management of ischemic stroke of other causes. Patients with CAD need long-term antithrombotic therapy for secondary stroke prevention. Anticoagulation or dual antiplatelet therapy followed by single antiplatelet therapy is recommended for extracranial CAD and antiplatelet therapy for intracranial CAD. Recurrent ischemic events and dissections are rare and typically occur early. Patients with CAD should avoid deep neck massage or chiropractic neck manipulation involving sudden excessive, forced neck movements., (Copyright © 2022 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Potential procedural complications of endovascular therapy for carotid artery dissection have not been clarified. Herein, we present the cases of a 46-year-old woman and a 59-year-old man who underwent carotid artery stenting for left cervical internal carotid artery dissection. During the procedure, intramural hematoma was squeezed out by stent placement, causing further extension of the pseudolumen and a prominent stenosis proximal to the stent. Additional stent deployment was subsequently performed to fully cover the newly arising stenosis, resulting in good recanalization. In cases with a long-affected lesion, we should consider the potential risk of dissection advancement following stent deployment. Using longer stents or additional rescue stenting would be efficient in counteracting this rare complication., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Abnormal styloid processes cause dissection of supra-aortic arteries in some cases. In total, about 33 cases have been described in the world and national literature. However, there were no dissections associated with neurosurgery. At the same time, anomalies of styloid process may be an unidentified cause of many spontaneous dissections of brachiocephalic arteries., Objective: To analyze modern data on dissection of brachiocephalic arteries associated with anomalies of styloid process and describe dissection in a 44-year-old patient with deviated styloid processes after posterior cranial fossa surgery., Material and Methods: Searching for literature data was performed using the keywords "dissection of the cervicocerebral arteries", "dissection of the brachiocephalic arteries", "stylocarotid syndrome" and "Eagle syndrome" in the PubMed and Medscape databases. We also describe a patient hospitalized for microsurgical resection of cystic-solid hemangioblastoma of medulla oblongata who developed postoperative dissection of both internal carotid and vertebral arteries., Results: We found 1777 papers between 01/01/1900 and 01/18/2021. In most cases, ICA dissection was not a result of stylocarotid syndrome. There were 121 full-text Russian- or English-language articles. We selected 46 most relevant publications. Analyzing these papers, we found that small distance between the tops of styloid processes and internal carotid arteries can be a risk factor of dissection of brachiocephalic arteries in addition to styloid process elongation. Our patient was diagnosed with just such an anomaly., Conclusion: Anomalies of styloid processes can cause dangerous vascular complications. Therefore, the length and abnormal deviation of styloid process should be considered when planning intraoperative position of a patient associated with prolonged neck flexion.

Introduction: Vascular Eagle syndrome, due to impingement of the extracranial internal carotid artery (ICA) by the styloid process (SP), is an uncommon and not yet widely recognized cause of ICA dissection. Up to now, this diagnosis is still presumptive, based mainly on the length of the SP. However, given the discrepancy between the much higher prevalence of an elongated SP in the population compared to the reported rate of Eagle syndrome, other anatomical factors beyond the length itself of this bony structure seem to be involved., Material and Methods: We performed a retrospective single center case-control study of ICA dissection related to abnormalities of styloid process and age- and sex-matched controls affected by ICA dissection not related to abnormal relationship with the styloid process. In our work instead of considering SP length as the main criteria to differentiate the two groups, we decided to consider styloid process-internal carotid artery distance (at the dissection point) as the main factor to define a styloid process related dissection (SPRD). In fact in some patients, the distance between the dissected artery and the bony prominence was virtual., Results: Our study showed that in patients with SPRD the styloid process angulation on the coronal plane tends to be more acute and that styloid process-C1 distance is significantly shorter at the side of the dissection. This data reinforces the idea that ICA dissection risk in the vascular Eagle syndrome has probably a multifactorial pathogenesis., (© 2021. Fondazione Società Italiana di Neurologia.)

Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Headache is a common symptom of cervical artery dissections (CAD). Sometimes, it can be the only symptom and mimic migraine. We aimed to investigate headache characteristics and previous history of migraine in CAD patients, and to compare headache features between patients with internal carotid artery dissection (ICAD) and vertebral artery dissection (VAD). We investigated 53 CAD patients (n = 28 with ICAD, n = 25 with VAD). Demographic and clinical data were evaluated retrospectively. Headache information was obtained from the patient interviews with a structured questionnaire (based on the International Headache Society criteria). The patients with headache were assessed by headache specialist with a face-to-face interview. Headache was evaluated according to International Classification Committee of the International Headache Society ICHD. Headache (n = 38, 71.7%) was the most common symptom in CAD patients, which was mostly thunderclap, throbbing, intense and ipsilateral to dissection. Headache frequency and neck pain were significantly higher in VAD patients (p = 0.002, p < 0.001, respectively). Photophobia and phonophobia were also more common in patients with VAD (p < 0.001, p < 0.001, respectively). 29 (54.7%) of CAD patients had a prior history of headache, that 20 (37.7%) of them met the migraine criteria. CAD should be considered in patients with severe unilateral throbbing headache with phonophobia and photophobia, even in patients with a history of migraine. Phonophobia and photophobia may be more common symptoms in VAD patients. Because headache commonly precedes the development of cerebral ischemic events, it needs prompt and accurate diagnosis and treatment., (© 2021. Belgian Neurological Society.)

Competing Interests: Competing interests: None declared.

Competing Interests: The authors report no conflicts of interest.

A 28-year-old man in 2004 was identified with a spontaneous pseudoaneurysm and distal left cervical internal carotid artery (ICA) dissection. The patient was followed conservatively for 12 years with cross-sectional imaging. The patient was initially diagnosed with an acute left ICA dissection, with significant luminal narrowing. Follow-up imaging revealed the dissection was not completely healed, and a small pseudoaneurysm, about 4 mm in size, was formed in the distal left cervical ICA. During the 12-year observation period, the patient's pseudoaneurysm expanded from 4.0 mm to 9.0 mm, and the patient presented with ptosis, anisocoria and myosis. Flow diverter embolisation resulted in a radiographic cure of the pseudoaneurysm and resolution of Horner's syndrome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)