Abstract Background Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare, multisystemic, immune-mediated inflammatory disease. Carotid artery dissections involving both the cervical internal carotid artery and common carotid artery are rare. To our knowledge, there are no previous reports of cervical carotid artery dissections associated with EGPA. This is the first report of spontaneous cervical artery dissection involving the common and internal carotid arteries associated with EGPA. Case presentation A 64-year-old woman with a history of EGPA presented with Horner syndrome. She was receiving glucocorticoids for EGPA and anticoagulation therapy for atrial fibrillation. Ultrasonography demonstrated an intimal flap and double lumen within the common carotid artery and internal carotid artery. The patient was followed up with continued medications. No ischemic stroke occurred, and Horner syndrome had improved at 6 month visit after onset. Ultrasonography showed no recurrence or aneurysm formation, but complete resolution of carotid artery dissections has not yet been confirmed. Conclusions This case suggests a possible association between EGPA and carotid artery dissections. In such cases, an underlying disease involving endothelial dysfunction should be investigated. Clinicians should consider underlying systemic vasculitis such as EGPA in cases of atypical or extensive cervical artery dissections.

Fibromuscular dysplasia (FMD) is a non-inflammatory arteriopathy that may result in arterial stenosis, dissection, aneurysm, and tortuosity. Data remain limited on clinical features and outcomes of patients with FMD presenting with spontaneous cervical artery dissection (SCeAD). This study aimed to describe the characteristics and long-term outcomes of this population. We conducted a retrospective multicenter cohort study of patients diagnosed with both SCeAD and FMD at three U.S. comprehensive stroke centers (2018-2023). Patients were identified through hospital records and vascular registries. Diagnosis of FMD and SCeAD was confirmed through imaging review by vascular neurologists or cardiologists. Outcomes included recurrent dissections, cardiovascular events (ischemic stroke, transient ischemic attack, myocardial infarction, subarachnoid hemorrhage) and mortality. Among 1,632 patients with SCeAD, 97 (6%) had FMD diagnosis. The cohort was predominantly female (91%) and median age at FMD diagnosis was 50 years(IQR 42-63). Carotid dissections were more frequent than vertebral dissections (86%vs.27%, p<0.001). Multiple dissections occurred in 32 patients (33%): 24 (75%) had bilateral dissections, 4(13%) had recurrent dissections in the same artery, and 7 (22%) had dissections in other vascular beds including the renal, iliac, mesenteric, and coronary arteries. Younger age [OR 0.945; 95%CI 0.908-0.983; p=0.005] and classical FMD "beading" on imaging [OR 3.06; 95%CI 1.28-7.36; p=0.012] were associated with multiple dissections. Aneurysms were detected in 27%, more frequently in patients with multiple dissections [OR 1.66; 95%CI 1.02-2.71;p=0.04]. Most patients were discharged on single (49%) or dual (29%) antiplatelet therapy and 22% received anticoagulation with no significant differences in event rates. Over a mean follow-up of 5±2.5 years, 13% developed recurrent dissections and 28% experienced cardiovascular events. Recurrent dissections were associated with future cardiovascular events [OR11.56; 95%CI 2.22-60.07; p=0.004]. FMD should be considered in patients presenting with SCeAD, particularly middle-aged women with multifocal dissections and no traditional vascular risk factors. There is an increased risk of dissection recurrence, future cardiovascular events and harboring aneurysms. These findings highlight the need for further prospective studies that can guide surveillance and management strategies for this high-risk population.

Carotid and Vertebral Artery Dissections.

Utilization of the Stop Short Technique in Transcarotid Artery Revascularization Doubles the Risk of Intraoperative Common Carotid Artery Dissection

Objective: To compare the clinical features of different treatment strategies between patients with type Ⅰ and type Ⅱ spontaneous extracranial carotid artery dissection (sECD). To investigate the efficacy of different treatment methods. Methods: A retrospective analysis was conducted on 181 sECD patients admitted to the First Affiliated Hospital of Zhengzhou University between June 2018 and February 2025, of whom 23 had bilateral involvement, resulting in a total of 204 dissected vessels. Based on the Borgess classification, 204 dissected vessels were categorized into 2 groups: type Ⅰ (intact intima, 71 vessels) and type Ⅱ (with an intimal tear, 133 vessels). Patients were followed up at 3, 6, and 12 months, and every 12 months thereafter via outpatient visits or readmission. Demographic data, clinical manifestations, imaging features, treatment regimens, and follow-up data were collected to analyze and compare the incidence of cerebral ischemic events, cerebral hemorrhage, and mortality during hospitalization and follow-up between the 2 groups. To observe the efficacy between surgical and conservative treatments as well. Results: A total of 181 patients aged (50±11) years were included, comprising 139 males and 42 females. Compared with type Ⅱ sECD, type Ⅰ were younger [48 (40, 56) vs 51 (44, 57) years, P=0.043] and had higher National Institute of Health Stroke Scale scores at admission and discharge [2 (0, 5) vs 0 (0, 3) points, P=0.029; and 0 (0, 2) vs 0 (0, 1) points, P=0.026, respectively]. The incidence of ischemic stroke was significantly higher in type Ⅰ sECD [60.6% (43/71) vs 43.6% (58/133), P=0.021]. Type Ⅰ sECD also exhibited a higher proportion of true lumen stenosis >70% [78.9% (56/71) vs 36.8%(49/133), P<0.001]. A total of 67 patients (71 vessels) underwent surgical treatment with a 100.0% (71/71) success rate and no perioperative complications. Among 114 patients (133 vessels) receiving conservative treatment, the cerebral ischemia recurrence rate was 3.7% (2/53) for type Ⅰ and 6.3% (5/80) for type Ⅱ, with no statistically significant difference (P>0.05). However, the complete and partial healing rates were higher in type I sECD than in type Ⅱ [88.7% (47/53) vs 30.0% (24/80), P<0.001]. Conclusions: Type Ⅰ sECD is more common in younger patients and is associated with a higher risk of severe ischemic stroke, yet it exhibits better healing rates with antithrombotic therapy. Surgical treatment intervention is safe and effective for both types.

Symptomatic nonstenotic (<50% stenosis) carotid disease in the presence of high-risk plaque features is a potential cause of ischemic stroke. We assessed stroke risk associated with symptomatic nonstenotic carotid disease. This cross-sectional secondary analysis of the AcT (Alteplase Compared to Tenecteplase) randomized controlled trial evaluated baseline computed tomography angiograms for degree of internal carotid artery stenosis, plaque features and the presence of intraluminal thrombi, webs, dissection, and rim sign. Stroke location was evaluated on 24-hour follow-up imaging. At a carotid level, mixed-effects logistic regression models adjusted for age and sex, with patient identity as a random effect, examined associations between "concordant stroke" (ipsilateral acute stroke in the internal carotid artery territory) and symptomatic nonstenotic carotid disease. Of 1577 patients enrolled, 1407 (89.2%) with interpretable imaging were included: 329 (23.4%) had no carotid disease, 869 (61.8%) had nonstenotic carotid disease, and 209 (14.9%) had stenotic (≥50%) carotid disease in either the left or right internal carotid artery. Median age was 73 years (interquartile range, 63-83), with 48% female patients. Among 2519 (89.5%) internal carotid arteries with nonstenotic disease, 689 (27.4%) concordant strokes were identified. Intraluminal thrombi, carotid webs, carotid dissections, and carotid rim sign were significantly associated with concordant stroke (adjusted odds ratio, 8.11 [95% CI, 1.60-41.08]; adjusted odds ratio, 3.58 [95% CI, 1.53-8.35]; adjusted odds ratio, 6.77 [95% CI, 1.72-26.75]; and adjusted odds ratio, 3.17 [95% CI, 1.39-7.23], respectively). Results remained unchanged after excluding patients with atrial fibrillation and lacunar infarctions. Features other than the degree of stenosis should be considered when evaluating patients with carotid disease.

A 4-year-old girl with traumatic carotid artery dissection and subsequent infarction of the middle cerebral artery

A man in his 50s experienced novel, continuous, and progressive headache and neck pain prior to the onset of left-sided peripheral facial nerve palsy. Sequential palsies of left lower Cranial Nerves IX and XII followed. Imaging showed spontaneous cervical artery dissection (sCeAD) of the ipsilateral internal carotid artery. Lower cranial nerve palsies in sCeAD are a frequent result of a local mass effect exerted by the formation of a mural hematoma. The only close topographical relationship between the facial nerve and the internal carotid artery is within the petrous part of the temporal bone but still separated in two different bony canals (facial canal and carotid canal). Thus, a mural hematoma of an internal carotid artery dissection could not cause compression of the facial nerve. In the rare case of facial nerve palsy due to sCeAD, hypoperfusion of the vasa nervorum is the most likely cause. As sCeAD is one of the main reasons for stroke in the youth, it is critical to know and identify potential red flags in patients with peripheral facial nerve palsy, which should lead to additional vascular imaging.

A 19-year-old female patient was brought to the emergency room following a traffic accident and electively orotracheal intubation due to a Glasgow coma score of 7. Ventilator therapy was discontinued. The patient had persistent right upper extremity ataxia. Therefore, a brain angiogram, followed by a head-neck-Computed tomography-angio, diagnosed an internal carotid artery dissection. We present the patient, who was treated and discharged with complete recovery.

Whether thrombectomy with or without emergent carotid stenting improves outcomes in patients with large vessel occlusion (LVO) stroke due to carotid artery dissection (CAD) is unknown. International multicentre observational study. Patients with LVO due to CAD undergoing thrombectomy with emergent stenting were compared to those without emergent stenting. The primary outcome was functional independence (modified Rankin Scale 0-2) at 3months, secondary outcomes included early neurological improvement (ENI) within 24-48h, successful recanalisation, symptomatic intracerebral haemorrhage (sICH) and mortality at 3months. Inverse probability of treatment weighting and multivariable Poisson regression were used to adjust for group imbalances and to estimate the effect size, respectively. Of 516 patients (mean age 53.8years, 76% male) undergoing thrombectomy, 167 (32.4%) and 349 (67.6%) were treated with or without emergent carotid stenting, respectively. After robust adjustment, emergent stenting was not associated with functional independence (adjusted risk ratio [aRR]=1.01; 95% confidence interval [CI], 0.89-1.15) or ENI (aRR=1.07; 95% CI, 0.95-1.21) but with successful recanalisation (aRR=1.29; 95% CI, 1.10-1.50) and reduced mortality at 3months (aRR=0.39; 95% CI, 0.15-0.99). Risk of sICH was equivalent (aRR=1.01; 95% CI, 0.95-1.06). In patients with LVO secondary to CAD, emergent stenting during endovascular procedure appeared safe, increased odds of successful recanalisation and reduced 3-month mortality rates. However, intraprocedural stenting was not associated with better functional outcome.

Intracranial atherosclerotic disease (ICAD) is a leading cause of stroke worldwide, with high rates of recurrent ischemic events in high-grade stenosis. Although endovascular treatment has faced challenges in early trials due to procedural complications and unfavorable outcomes, recent advancements in drug-eluting stents, such as the Resolute/Frontier Onyx (Medtronic), offer a promising alternative to bare-metal stents. This study evaluates the safety and efficacy of Resolute/Frontier Onyx in treating symptomatic ICAD. We conducted a retrospective, single-center study of 22 patients with symptomatic ICAD who underwent stenting with Resolute/Frontier Onyx. Inclusion criteria included ≥70% stenosis and recurrent stroke or transient ischemic attack, despite optimal medical therapy. Baseline characteristics, procedural details, and clinical outcomes were extracted from electronic medical records. Primary outcomes included cerebrovascular event recurrence (stroke or intracranial hemorrhage) and symptomatic in-stent restenosis. Descriptive statistics were used for analysis. The median age was 65 years (IQR, 61-72), and 72.7% (16/22) of patients were male. Hypertension was present in 90.9% (20/22), and the median time from the qualifying event to stenting was 1 day (IQR, 1-3). Procedural complications occurred in 4.5% (1/22) of patients and consisted of a common carotid artery dissection that occurred during stent insertion. At a median follow-up of 12 months (IQR, 6-23), no strokes or intracranial hemorrhages were reported. Symptomatic in-stent restenosis occurred in 9.0% (2/22) of patients, with 1 requiring reintervention. Residual stenosis of ≥30% was observed in 26.6% (4/15) of patients who underwent follow-up imaging. The Resolute/Frontier stent demonstrated favorable safety and efficacy in this cohort, with low procedural complication rates and no recurrent strokes or intracranial hemorrhages at follow-up. These findings, along with previous evidence supporting drug-eluting stents, highlight the potential of Resolute/Frontier Onyx as a promising therapeutic option for symptomatic ICAD.

No definite recommendations exist for anesthetic and obstetric management of pregnant patients with intracranial neurovascular disorders during delivery. This case series describes the management of pregnant patients with intracranial vascular abnormalities during delivery. Information was gathered from institutional databases to include pregnant patients evaluated by neurology or neurosurgery at a single institution between January 2000 and August 2025 for any central nervous system vascular abnormality. Patients were included if evaluation by neurology or neurosurgery occurred either before, during pregnancy, or up to six months post-partum. The study cohort consisted of 26 patients having 31 deliveries. The most common lesions were cavernous malformation (n = 8) and cerebral arteriovenous malformation (n = 8). The remainder had aneurysm (n = 4), dural arteriovenous fistula (n = 2), moyamoya disease (n = 2), venous angioma (n = 1), and carotid dissection (n = 1). Twenty-one deliveries were vaginal and 10 were cesarean delivery (CD). The presence of a neurovascular abnormality was an indication for induction of labor in three individuals and for CD in four deliveries. Neuraxial labor analgesia was used in 14 of the 21 patients who had vaginal delivery. Parturients who underwent CD had spinal anesthesia (n = 8), preexisting labor epidural anesthesia (n = 1), and general anesthesia (n = 1). There were no complications attributed to neuraxial anesthesia. The presence of central nervous system vascular abnormalities in pregnant patients is rare but poses unique challenges to obstetric and anesthetic management. Neuraxial anesthesia and analgesia can be offered to women with central nervous system vascular abnormalities without abnormal neurologic symptoms.

Carotid artery dissection is a rare but significant cause of pediatric stroke, often associated with trauma or underlying collagen vascular disorders. The management of these cases, both medical and surgical, is complex, particularly in bilateral dissections where collateral circulation may be insufficient. We describe a case of bilateral internal carotid artery occlusion that developed 10 days after an initial traumatic fall. The progression of ischemic stroke burden and fluctuating neurologic status, despite therapeutic anticoagulation and optimal medical management, led to the decision for endovascular intervention involving balloon angioplasty and stenting. Following the procedure, a rapid improvement in neurologic function was observed, with the patient exhibiting only mild deficits at discharge. This case highlights the complexities in managing pediatric carotid dissections, especially in unusual presentations. Our experience underscores the necessity for tailored treatment strategies, rigorous monitoring, and a multidisciplinary approach to optimize outcomes in pediatric stroke patients.

ABSTRACT Objective Highlight the importance of recognizing stationary waves as a differential diagnosis of fibromuscular dysplasia, especially in the context of arterial dissection. Methods Presentation of a case report and different CT and MRI angiographic images on stationary waves. Results Stationary waves may represent a transient physiological vessel response to upstream resistance and its MRI angiographic images can be misinterpreted as fibromuscular dysplasia. Conclusion Vascular imaging of concentric luminal stenosis and ectasias should have stationary waves as a differential diagnosis for fibromuscular dysplasia.

Safety and Efficacy of Spontaneous Carotid Artery Dissection Management with Transfemoral Carotid Artery Stenting and Transcarotid Artery Revascularization: A Multi-Institutional Study.

Background: Internal carotid artery dissection is an uncommon yet important cause of ischemic stroke in young individuals without any known cerebrovascular risk factors, often resulting in high morbidity and mortality. When patients exhibit significant neurological deficits following blunt trauma to the head or neck, carotid artery injury should be suspected until ruled out. Early detection and intervention guided by a structured algorithm, can help prevent severe brain damage.

Cervical artery dissection is one of the leading causes of ischemic stroke in young adults, and poses unique diagnostic and therapeutic challenges due to an often nonspecific clinical presentation. Prompt recognition is essential, as early ischemic events are common within the first 2 to 4 weeks. This review summarizes current evidence on the epidemiology, pathophysiology, clinical features, diagnostic strategies, and management of cervical carotid artery dissections. While antithrombotic therapy is the mainstay of secondary stroke prevention, the optimal choice between antiplatelet and anticoagulation remains uncertain. Randomized trials and large cohort studies suggest similar efficacy between antiplatelet and anticoagulant therapies, though anticoagulation may confer benefit in patients with vessel occlusion. Recurrent dissection and ischemic events are rare, and dissecting aneurysms generally have a benign course. Endovascular intervention is reserved for select cases. A tailored, risk-based approach to therapy-guided by clinical and radiographic features-is essential to improve outcomes in this complex and heterogeneous population.

Intracranial carotid dissecting aneurysms (DA) are often treated emergently upon diagnosis. In contrast, extracranial DA are generally considered less likely to rupture and are commonly managed conservatively. Despite these clinical differences, limited data exists on the hemodynamic differences that might explain their divergent clinical behaviors. Retrospective analysis of intracranial and extracranial DA treated between 2011 to 2023. DA were reconstructed from computerized angiographic images using 3D Slicer software. Computational fluid dynamics (CFD) simulations were performed using ANSYS® Fluent package. Hemodynamic parameters calculated included time averaged wall shear stress (TAWSS), high shear areas (HSA), low shear areas (LSA), time averaged wall shear stress ratio (TAWSR), oscillatory shear index (OSI), and relative residence time (RRT). We compared these variables between extracranial and intracranial lesions using Mann-Whitney U and t-tests. Nineteen DA (10 extracranial, 9 intracranial) from 16 patients (age 48-82; 9 male) were analyzed. The average volume and area of the lesions evaluated were 187 mm3 and 158.6 mm2. Two of the intracranial DA were identified in the setting of subarachnoid hemorrhage. Extracranial DA showed significantly greater volume (234.6 vs. 83.0 mm3; p = 0.02) and area (210.9 vs. 59.4 mm2; p = 0.03). Intracranial DA demonstrated nonsignificant trends toward lower TAWSS at the aneurysm (1.04 vs. 1.53Pa; p = 0.62), lower TAWSSR (0.49 vs. 0.7; p = 0.19), greater LSA (4.2% vs. 2.7%; p = 0.28) and higher RRT (2.16 vs. 1.36 m2/N; p = 0.29). This study identified hemodynamic trends in intracranial DA (higher LSA and higher vessel wall TAWSS in relation to the DA) that may account for the differential clinical behavior and increased risk of rupture.

Our understanding of carotid artery dissections has substantially increased over the past decade. We now know much more about the pathophysiology, imaging appearance, and medical and interventional management of dissections. Still, many radiologists remain unaware of the changing landscape in this field. This article set out to highlight the most up-to-date information about this pathology with a focus on the CT and MR imaging characteristics, new imaging frontiers, and treatment options for dissections.

Introduction. Common carotid artery dissection (CCAD) is a rare (2–3 cases per 100,000 population per year) but clinically significant vascular pathology that often leads to ischemic stroke, particularly in young and middle-aged individuals. Diagnosis of CCAD presents certain challenges, especially in the presence of underlying atherosclerosis or traumatic injury, which may mask the vascular lesion. Computed tomography angiography (CTA) is currently the most informative method for detecting dissections. Aim. To present a clinical case of CCA dissection diagnosed at a late stage in the management of a patient with ischemic stroke. Materials and Methods. A case is described of a spontaneous dissection in a 43-year-old male patient who was admitted to a medical rehabilitation unit following an ischemic stroke. Clinical data and findings obtained by instrumental investigation methods are presented. Results and Discussion. During the diagnostic process, including examina- tions performed during the rehabilitation phase, signs of dissection in the distal segment of the right CCA were revealed, with intimal flap formation and more than 70% luminal stenosis. As a result, surgery was planned and performed, i.e., prosthetic ССА. Based on the data from his initial hospitalization, including clinical history and instrumental diagnostics, a spontaneous dissection of the distal CCA was assumed, likely with a traumatic component, leading to the development of an ischemic stroke. Conclusions. This clinical case emphasizes the importance of sequential vascular imaging in ischemic strokes of unclear etiology. This case highlights the importance of staged vascular imaging in ischemic strokes of unclear etiology. CTA and ultrasound of the neck vessels allowed to verify the dissection of the common carotid artery and to adjust the treatment tactics. The results obtained confirm the CTA significance in the examination of patients with stroke of unclear etiology for timely diagnosis of rare but clinically significant vascular lesions.