Spontaneous bilateral internal carotid and vertebral artery dissections with dominant-hemisphere circulation maintained by external carotid artery-ophthalmic artery anastomoses

Spontaneous cervical artery dissection (sCAD) is a major cause of stroke in young adults. Multiple sCAD is a rarer, more poorly understood presentation of sCAD that has been increasingly attributed to cervical trauma such as spinal manipulation or genetic polymorphisms in extracellular matrix components. The authors present the case of a 49-yearold, otherwise healthy woman, who over the course of 2 weeks developed progressive, hemodynamically signifiant, bilateral internal carotid artery and vertebral artery dissections. Collateral response involved extensive external carotid artery-internal carotid artery anastomoses via the ophthalmic artery, which were instrumental in maintaining perfusion because circle of Willis and leptomeningeal anastomotic responses were hampered by the dissection burden in the corresponding collateral vessels. Endovascular intervention by placement of Pipeline embolization devices and Atlas stents in bilateral internal carotid arteries was successfully performed. No syndromic or systemic etiology was discovered during a thorough workup.