Bilateral spontaneous internal carotid artery dissection; a treatment dilemma: A case report and literature review

Abstract

Introduction: Spontaneous carotid artery dissection in association with exercise is well known. A bilateral occurrence is a rarely reported finding. SVS guidelines discussed the role of antiplatelets and anticoagulants in management, however, management of dissections associated with pseudoaneurysm formation is still controversial. Herein, we report a case of walking-induced spontaneous bilateral carotid artery dissection complicated by a unilateral pseudoaneurysm formation treated conservatively with satisfactory outcome.

Case presentation: A 41-year-old male presented with a sudden severe headache, blurred vision, and transient right upper limb weakness after a long walk. Initial CT angiography showed bilateral carotid artery dissection. The patient was managed conservatively with antiplatelet therapy and close follow up. Follow-up imaging showed gradual resolution of the dissection bilaterally and a stable right internal carotid artery pseudoaneurysm. Five years later, the patient remained asymptomatic with shrinking ICA pseudoaneurysm.

Discussion: Bilateral spontaneous carotid artery dissection is a rare condition that can present with stroke-like symptoms, including visual changes and motor deficits, as observed in the presented case. Conservative management with antiplatelet therapy showed a favorable outcome, aligning with the recommendations of the SVS guideline. The role of antiplatelet therapy in managing pseudoaneurysms as a complication of dissection remains controversial, with endovascular interventions generally preferred despite reported complications. However, in our case, conservative management with antiplatelet therapy showed satisfactory outcomes, as supported by some recent studies.

Conclusion: The reported case presents a rare occurrence of spontaneous bilateral carotid artery dissection complicated by a unilateral pseudoaneurysm formation. Conservative treatment with antiplatelets is associated with good outcomes, and potentially in highly selected patients complicated with pseudoaneurysm formation.

Keywords: Antiplatelet therapy; Bilateral carotid artery dissection; Case report; Conservative management; Vascular surgery.