Spontaneous triple vessel cervicocephalic artery dissection in a young gentleman: A case report.

Introduction: Cervicocephalic arterial dissections (CADs) occur in 3 cases per 100,000 individuals across all ages. Multiple simultaneous CADs are found in 13 to 22% of cases, and three or more dissections occur in approximately 2%. CADs might result from multifactorial intrinsic deficiencies of vessel wall integrity and extrinsic factors, e.g., minor trauma.

Case Presentation: A young gentleman presented to the emergency department with a sudden onset of a spinning sensation of surrounding, left side arm weakness, blurring of vision, and an NIHSS score of 4. An urgent CT scan of the head and intracranial angiogram showed bilateral severe stenosis of the distal cervical segment of internal carotid arteries (ICAs) and right vertebral artery moderate stenosis at the V2 segment. He had been given IV TPA (Alteplase) within the 4.5-hour window. After 4 hours, the patient's GCS dropped from 15 to 10, and the NIHSS score increased from 4 to 24, followed by witnessed a generalized tonic-clonic seizure. Repeat urgent CT head showed no evidence of intracerebral hemorrhage (ICH). The patient was arranged for cerebral angiographic catheterization that showed bilateral flame-shaped occlusion of cervical ICA dissection. There is a mild focal narrowing of the right cervical vertebral artery, likely dissection. Routine laboratory blood workup for vasculitis was negative. During MICU admission, he had witnessed the right arm hemichorea-ballism spectrum abnormal movement. After the 6th-month follow-up, intracranial CT angiogram showed reduced caliber of the bilateral distal cervical course of the internal carotid arteries seen with residual dissection and focal outpouching of the right ICA representing pseudoaneurysm.

Discussion: The occurrence of multiple CADs suggests the presence of an underlying intrinsic arteriopathy, such as FMD, the presence of pseudoaneurysm, environmental triggers, cervical manipulation, and remote history of head or neck surgery. A study of the most extensive case series of patients with cervical artery dissection showed 15.2% of patients with multiple CAD. In most patients with multiple cervical artery dissections, antithrombotic treatment is effective, complete recanalization, and the outcome is favorable. Outside the window period of acute ischemic stroke, either anticoagulation or antiplatelet therapy is a recognized treatment for secondary ischemic stroke prevention due to extracranial artery dissection. For acute stroke or TIA patients caused by intracranial artery dissection, experts recommend antiplatelet therapy rather than anticoagulation.

Conclusion: Simultaneous triple-vessel cervicocephalic arterial dissections are rarely reported condition. Multiple CADs are associated with underlying vasculopathy and environmental triggers, and a majority are recanalized with antithrombotic treatment with favorable outcomes. Antithrombotic treatment is effective in most patients with multiple CADs, and most expect complete recanalization. This case report guides physicians in the treatment and outcome of acute stroke due to multiple CAD.