Convexity subarachnoid hemorrhage revealed contralateral internal carotid artery dissection due to Eagle syndrome: a case report.

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.

Cerebral infarction caused by coexisting elongated styloid process and carotid web.

OBJECTIVE: Elongated styloid process (ESP) and carotid web are rare etiologies of ischemic stroke. We report a rare case of ESP concomitant with carotid web as the cause of recurrent stroke. CASE PRESENTATION: A 59-year-old man was admitted to our hospital with recurrent numbness and weakness in the right upper extremity. The patient had a long-standing history of lightheadedness and left-side amaurosis with neck flexion. Magnetic resonance imaging (MRI) confirmed scattered infarctions in the left frontal and parietal lobes. After multi-modal imaging we determined that embolic cerebral infarction was most likely to be secondary to the carotid web. Moreover, ESP causes dynamic hypoperfusion during neck flexion. We believe that this is a good reason for dealing with both pathologies during the same surgery. Thus, carotid endarterectomy and styloid process resection were performed at the same time. The previous symptoms during the head position change did not recur, and the right hand weakness was resolved. CONCLUSION: ESP and carotid web are unusual mechanisms of ischemic stroke. Early diagnosis and timely treatment are essential to prevent subsequent severe strokes.

The prevalence of elongated styloid process in the population of Barcelona: a cross-sectional study & review of literature.

BACKGROUND: Styloid process (SP) is a cylindrical bony projection that originates from the inferior part of the petrous temporal bone just anteriorly to the stylomastoid foramen. Several nerves, muscles, and ligaments are related closely to the (SP). It is considered elongated when the measurement exceeds 30 mm. The overall prevalence of the styloid process is between 3.3% to 84.4%. The elongation of the styloid process (ESP) is associated with the manifestation of Eagle's Syndrome (ES) which is characterized by various types of pain in the head and neck region such as headache, tinnitus, otalgia, and trigeminal neuralgia. Eagle's syndrome occurs in 4-10.3% of individuals with an elongated styloid process (ESP). The objective of the study is to determine the prevalence of (ESP) in the patients who were treated in the Dental Hospital University of Barcelona (HOUB), to review the literature to spot the light on the different demographic data worldwide. METHODS: The archived panoramic image in the University of Barcelona dental Hospital were consecutively retrieved to investigate the prevalence of (ESP). Of all digital panoramic radiographs (OPG), 400 met the inclusion criteria and were furtherly analyzed. The results are correlated with the participant's gender, age, and occurrence. Age is subcategorized into three groups. A chi-square test is used to measure the significant differences and the P-value is set at < 0.05 for the level of significance. RESULTS: Among the included 400, we found 291 demonstrating (ESP). The prevalence of (ESP) which exceeds 30 mm is 72.75%. It is found that the most common morphological type is type 1 which is regarded as the uninterrupted (ESP) regardless of gender and age group. Concerning the calcification pattern, the most prevalent is the partial calcified (ESP) despite genders and age groups. CONCLUSION: (OPG) is a sufficient tool for the screening of the elongated styloid process. Regarding the prevalence, our results are considered higher than previously reported prevalence in different populations using (OPG) radiography tool. A study on a wider spectrum of the Spanish population is recommended to further investigate the correlation between the elongated styloid process and the occurrence of Eagle's syndrome.

Prevalence and features of elongated styloid process on imaging studies: a systematic review and meta-analysis.

OBJECTIVE: To determine the prevalence of the elongated styloid process (ESP) and its characteristics, such as sex and age of the patient, unilateral and bilateral incidence, besides variations between different populations and panoramic and CBCT examinations. MATERIALS AND METHODS: A search was performed in six databases (PubMed, Web of Science, Scopus, Cochrane, Lilacs, and Embase) to identify observational studies that used imaging exams and assessed ESP prevalence among panoramic radiograph CBCT examinations, whose transversal prevalence studies were included. Furthermore, studies with a specific group of patients or symptomatic patients were excluded. Additionally, Joanna Briggs Institute checklist was used to evaluate the quality of the studies. A meta-analysis was conducted, then subgroup analyses were performed by grouping studies according to the secondary outcomes, with a significance level set at 5%. The Grading of Recommendations Assessment, Development, and Evaluation system was used to rate the certainty in the evidence. RESULTS: The initial search resulted in 1635 studies, from which 39 articles met the inclusion criteria, encompassing 50,655 participants. The sample size varied between 82 and 5,000 participants. The prevalence of the ESP ranged from 1.3 to 94.8%, with an overall prevalence of 30.2%. The bilateral occurrence was higher than the unilateral one, but no significant predilection was observed according to sex, age, or population. The type of imaging examination also showed no difference in its detection. CONCLUSION: The overall prevalence of ESP was 30.2%, with a propensity for bilaterality, but not for any sex, age, or population geographic location. The imaging examination modality did not influence the diagnosis of ESP. However, the quality level of the studies evaluated was very low, demonstrating the need for more homogeneous primary studies on the prevalence of the ESP with a more standardized methodology. CLINICAL RELEVANCE: There is no consensus in the literature regarding the prevalence of the ESP and the characteristics of the affected patients that can cause chronic and debilitating discomfort in the head and neck region. Therefore, knowledge about the prevalence and characteristics of this condition would help dental clinicians reach the correct diagnosis.

Carotid Micromesh Stent for the Cervical Carotid Artery Dissecting Aneurysm in a Patient with Vascular Eagle Syndrome.

OBJECTIVES: An elongated styloid process may cause vascular Eagle syndrome that includes cervical carotid artery (CCA) dissection with stenosis and aneurysm formation. There are only four reported cases with vascular Eagle syndrome-related CCA dissecting aneurysm treated with carotid artery stenting (CAS). This is the first report of applying a dual-layer nitinol micromesh stent (CASPER) for vascular Eagle syndrome-related CCA dissecting aneurysm. CASE PRESENTATION: A 38-year-old man presented with a sudden onset of aphasia and right hemiplegia. Cerebral angiography demonstrated the left CCA dissecting aneurysm. The superior trunk of the left middle cerebral artery (MCA) was also occluded, and emergent thrombectomy was performed. Computed tomography with angiography (CTA) revealed that a 33 mm-long styloid process compressed the CCA at the aneurysm formation. Three weeks later, a CASPER stent was applied for the CCA aneurysm under the flow reversal system. Immediately after stent placement, blood flow in the aneurysm became stagnant, and postoperative CTA demonstrated regression of the aneurysm. The aneurysm did not recur for 6 months with no styloid process resection. CONCLUSIONS: The dual-layer nitinol micromesh stent (CASPER) was useful to treat vascular Eagle syndrome-related CCA dissecting aneurysm.

Eagle Syndrome: 3D endoscope-assisted anterior tonsillar fossa approach to styloid process.

BACKGROUND: The aim of this study was to describe the potential advantages of the 3D endoscope-assisted anterior tonsillar fossa approach to elongated styloid process. METHODS: A 58 years-old woman was reported to our Department with one-year history of odynophagia, latero-cervical pain on the left side, and ipsilateral foreign body sensation. Pain was dull and intermittent in nature. The patient had visited different clinics, she had a physiatric and maxillo-facial evaluation with two dental extraction without any relief of the symptoms. On physical examination a hard-bony consistency area was palpated over left-sided tonsillar fossa, evocating severe pain. Three-dimensional computed tomography (CT) confirmed an anomalous length of the left styloid process and a diagnosis of Eagle's syndrome (ES) was made. After careful surgical and anesthesiology evaluation, we decided to proceed with the partial excision of the styloid process with a 3d endoscope-assisted transoral anterior tonsillar fossa approach (Reddy et al., 2020). RESULTS: The patient was relieved of her symptoms after the surgery and was discharged after 1 day. Postsurgical healing was uneventful, pharyngodynia was observed for the first 48 h and treated with anti-inflammatory medication. No early or late postoperative complications, including massive bleeding, neurovascular injury or infection, were encountered. At 1 year follow up visit the patient was still asymptomatic and the CT scan did not show any abnormalities. The 3D endoscope provided a high-quality magnification of the tonsillar fossa, which allow us to correctly identify the site of incision. Styloid process was identified through digital palpation. After sufficient dissection of the tip, the distal part of the elongated styloid process was osteotomised and retrieved with a curved instrument. Local hemostasis was achieved and wound was closed in layers. CONCLUSION: Some authors suggested novel surgical approach for ES like transoral robotic surgery (Rizzo-Riera et al., 2020 [2]). We present the 3D endoscope-assisted anterior tonsillar fossa approach as a feasible alternative for the surgical management of ES. Our experience with this approach has been outstanding, guaranteeing an optimal vision and depth of the surgical field with safe manipulation of the instruments which avoided injuries to healthy tissue. Furthermore, 3d endoscope was a great didactic tool. In our opinion is not necessary to remove all the styloid process, as other authors suggest (Lisan et al., 2019 [3]), but is sufficient a partial styloidectomy after cutting the stylohyoid ligament.

A pain like no other: From cluster to headache to Eagle's syndrome, a case report.

BACKGROUND: Eagle's syndrome, also called stylohyoid complex syndrome, is a rare syndrome pathology characterised by latero-cervical pain radiating to the face, linked to an abnormal enlargement of the styloid or calcification of the stylo-hyoid ligament. CASE: We report here the case of a young man of 25 suffering from cluster headache resistant to treatments, revealing Eagle's syndrome. CONCLUSION: Only surgery led to a real improvement of his condition.

The Syndrome of Elongated Styloid Process, the Eagle's Syndrome-From Anatomical, Evolutionary and Embryological Backgrounds to 3D Printing and Personalized Surgery Planning. Report of Five Cases.

Background and Objectives: The symptoms of Eagle's syndrome are associated with the elongated styloid process of the temporal bone or calcification of the stylohyoid ligament. The first mention of pain syndrome associated with the elongated styloid process dates back to 1937, when it was described by Watt Weems Eagle. Over the last decade, experts in the field have shown a lively interest in the issue of the relationship between the elongated styloid process and various symptoms. This article presents the correlation between the clinical signs of Eagle's syndrome and alterations in surrounding anatomical structures. It includes a brief review of the evolutionary, embryological and clinical anatomical background of the elongated styloid process. Materials and Methods: Between 2018 and 2019, five patients were admitted to our workplace with 1-3-year history of bilateral or unilateral throat pain, otalgia and pharyngeal foreign body sensation. As a therapeutic novelty in the surgical approach to this condition, we used individual 3D printed models to measure and identify the exact location of the resection of the styloid process without damaging the surrounding anatomical structures, such as the facial, accessory, hypoglossal, and vagal nerves; the internal jugular vein; and the internal carotid artery. Results: Compared to traditional surgical methods without 3D models, 3D models helped to better identify cutting edges and major landmarks used in surgical treatment of Eagle's syndrome. Printed models provided assistance with the exact location of the styloid process resection position without damaging the surrounding anatomical structures such as the facial, accessory, hypoglossal, and vagal nerves; the internal jugular vein; and the internal carotid artery. Conclusion: In our clinical report, we used 3D printed models for navigation and planning during surgical procedures involving resections of the elongated styloid process. Additionally, we can formulate a new hypothesis: the elongated styloid process is a form of atavism of the bony hyoid apparatus in our evolutionary ancestors that is evolutionarily encoded or arises from disrupted degeneration of the middle portion of embryonal Reichert´s cartilage of the second pharyngeal arch. Under normal conditions, this portion does not ossify but degenerates and transforms into a connective tissue band, the future stylohyoid ligament.

The eagle jugular syndrome.

BACKGROUND: The elongation of the styloid process is historically associated with two variants of the Eagle syndrome. The classic one, mainly characterized by pain and dysphagia, and the carotid variant characterized by pain and sometimes by cerebral ischemia. We observed a further variant characterized by a styloid elongation coursing adjacent to the transverse process of C1, causing significant compression of the internal jugular vein. METHODS: We reviewed all the cases of Eagle syndrome, including the jugular variant, admitted in our Hospital in the last six years. We compared symptomatology, associated comorbidities and imaging. Data were statistically analyzed. RESULTS: Overall 23 patients were admitted to the Hospital for symptomatic elongation of the styloid process, 11 male and 12 females. The jugular variant of the Eagle syndrome is clinically delineated by significant differences, as compared to the classic variant and carotid variants. Headache was the more prominent symptom (p < .009) as well as a documented peri-mesencephalic hemorrhage was the more significant comorbidity (p < .0003). The group classic-carotid variant was characterized by ipsilateral pain respect to the jugular variant (p < .0003). CT angiography with venous phase extended to the neck veins and imaging reconstruction is highly recommended as imaging technique, complemented by color-Doppler ultrasound. CONCLUSIONS: The elongation of the styloid process may have different paths which creates compression on the surrounding anatomical structures. There may be a possible association of jugular impingement by an elongated styloid process with symptoms. TRIAL REGISTRATION: Protocol n°45-2013.

Internal jugular vein stenosis associated with elongated styloid process: five case reports and literature review.

BACKGROUND: Internal jugular vein stenosis (IJVS), characterized by a series of clinical manifestations, such as head and neck symptoms, visual and ear symptoms, as well as sleep disorder, has been receiving attention in recent years. However, its' etiologies are not fully understood. CASE PRESENTATION: We report a cases series of IJVS induced by styloid oppression. We define it as the stylo-jugular type of Eagle syndrome (ES). CONCLUSIONS: Our study reveals that external oppression, especially by styloid process, is an important etiology of IJVS. The stylo-jugular ES diagnosis can be identified by Computed tomography venography. Whether stylo-jugular ES can be corrected by styloidectomy requires further investigation.

A Case of Juvenile Stroke due to Carotid Artery Dissection from an Elongated Styloid Process-Revisiting Conservative Management.

Carotid artery dissection is a significant etiology of juvenile stroke. Blunt trauma from an elongated styloid process can rarely cause carotid artery dissection, which is one of well-known clinical presentations of Eagle's syndrome as known as stylocarotid syndrome. Growing number of publications contributed improved awareness and diagnostic modalities for this clinical entity, thus the carotid artery dissection from an elongated styloid process is often diagnosed appropriately. The management of carotid artery dissection in stylocarotid syndrome tends to be nonconservative (ie, removal of the process or carotid stenting) presumably due to a publication bias prone to surgical intervention. However, the compression of elongated styloid process to carotid artery is usually difficult or even dangerous to directly prove. Furthermore, stent fracture with subsequent stent and carotid artery occlusion has been reported as a complication of the treatment. Here, we report a male presenting with acute embolic stroke due to carotid artery dissection with the ipsilateral elongated styloid process who has been managed conservatively for more than 1.5 years without any sequelae. We will discuss the management strategy and emphasize the importance of patient education of daily life, since the surgical intervention seems not always necessary in this clinical setting.

Bilateral hypoglossal nerve paralysis following elongated styloid process resection: case report.

We report a case of anesthetic management of a 43-year-old patient with Eagle's syndrome (ES) in whom post-extubation acute airway obstruction occurred due to bilateral hypoglossal nerve paralysis. After an accurate examination, elongated bilateral stylohyoid ligament was observed and surgical resection was planned. After completion of the surgery following extubation, significant dysfunction in swallowing, speech function, and tongue motion was observed. The clinical situation was evaluated as bilateral hypoglossal nerve paralysis related to the procedure. The patient was closely observed over 48 h in the intensive care unit. After 2 days, the patient was discharged to a surgical ward. Following clinical assessment, the patient was discharged from hospital for monthly return. At the 6-month follow-up, there were no further episodes of paresthesia and other symptoms. In conclusion, patients with ES represent a real challenge for physicians from diagnosis to treatment, especially regarding perioperative complications, and close collaboration between surgeons and anesthesiologists is of crucial importance.

Does the state of dentition effect the type of stylohyoid chain calcification pattern?

INTRODUCTION: The human stylohyoid chain calcification patterns (SCP) present considerable anatomic variability. This study was performed to investigate the calcification on SCP in the dentate and total edentulous population and its relation to mandibular protrusive movement. MATERIALS AND METHODS: The study analyzed 1.234 SCP in digital panoramic radiographs of 617 subjects. The SCP were classified according to Mac Donald-Jankowski. The amount of mandibular protrusion movement limitation was evaluated for each subject. The data were analyzed using one-way Anova, Kruskall Wallis, Mann-Whitney U, and Chi-squared tests with significance set at p = 0.05. RESULTS: Among the 617 subjects evaluated there was symmetry of the SCP between the left and right sides in 87.3 % of the cases. In the study population 501 subjects were dentate (Class I, Class II, Class III molar relationship) and 116 subjects were total edentulous. There were significant differences among dentate and total edentulous patients for the distribution of SCP (p < 0.05). Elongated group was more prevalent in total edentulous subjects while in subjects with Class I occlusion normal SCP was observed. Although mandibular protrusive movement range was within normal limits for all the groups, calcified and elongated groups have numerically less protrusive movement compared to normal groups (p < 0.05). CONCLUSION: Among dentate and total edentulous subjects, similarity in SCP for right and left side was observed. The elongation of SCP was more common in the total edentulous group. Further studies conducted on larger populations are necessary to establish the effect of the state of dentition on the SCP.

Eagle syndrome: an incidental finding in a trauma patient: a case report.

BACKGROUND: Eagle syndrome is a rare condition characterized by an elongated styloid process that occasionally irritates or disrupts adjacent anatomical structures. Although this is well known in the literature, it is rarely on the forefront of the clinician's mind. In the trauma patient, awareness of Eagle syndrome and knowledge of the anatomy associated with it may help differentiate symptoms secondary to acute injury from the chronic symptoms of this syndrome. OBJECTIVES: To review the diagnostic and treatment modalities related to Eagle syndrome and its associated anatomical structures germane to the trauma patient. CASE REPORT: A 42-year-old African American man presented with neck, face, head, and back pain after being assaulted. The patient noted that he had a long history of foreign body sensation on the right side of his neck with occasional difficulty swallowing. On physical examination, the patient was found to have a solitary, 1-cm laceration in the left parietal scalp. The physical examination was unremarkable other than scalp hematoma and laceration. Computed tomography scans of the head, face, and cervical spine were negative for acute injury other than a small scalp hematoma, and a markedly enlarged right styloid process, measuring approximately 8 cm, with ossification of the stylohyoid ligament to the level of the hyoid bone. CONCLUSION: In the trauma patient, awareness of Eagle syndrome and knowledge of the anatomy associated with it may help differentiate symptoms secondary to acute injury from the chronic symptoms of this syndrome.

The graft kinking of high-flow bypass for internal carotid artery aneurysm due to elongated styloid process: a case report.

Elongated styloid process is an often-caused symptom due to the compression of neighboring structures. We present a case of a graft kink of high-flow bypass due to an elongated styloid process and describe the technical pitfalls encountered when creating a graft route from the standpoint of the anatomical site.

Role of the Surgical Approach in the Treatment of Eagle Syndrome.

Introduction Eagle syndrome is a rare and an often misdiagnosed entity in otorhinolaryngology. Objective To determine the efficacy of the surgical treatment for Eagle syndrome. Methods The present prospective study included 25 patients who presented with complaints of pain in the throat, ear, and neck, as well as difficulty and/or pain while swallowing; they were assessed for Eagle syndrome. As per patient profile, we performed a clinical assessments along with orthopantomograms (OPGs), three-dimensional computed tomography (3D CT) scans, and cone beam computed tomography (CBCT). Pain was assessed pre- and postoperatively through the Numerical Rating Scale-11 (NRS-11), whose score ranges from 0 to 10. Microscopic tonsillo-styloidectomy was performed in cases in which the conservative treatment failed to relieve pain. Results The mean age of the entire study population was of 36.08 ± 7.19 years, and the male-to-female ratio was of 1.08:1. Referred otalgia was the commonest (44%) complaint. Radiologically, out of 25 patients, 20 patients presented elongated styloid processes. The longest symptomatic styloid process measured radiographically was of 64.7 mm while the shortest was of 28.2 mm. Out of 20 patients, 12 underwent surgery. The postoperative pain assessment through the NRS-11 was performed on day 0 (3.83 ± 0.83), day 7 (1.5 ± 0.52), week 4 (0.5 ± 0.52), and week 12 (0.41 ± 0.51). By 12 weeks, 7 patients were symptom-free, while 5 patients still reported mild pain. Conclusion Eagle syndrome associated with an elongated styloid process is not a rarity, but it often goes undiagnosed. Microscopic tonsillo-styloidectomy shows excellent results in the management of patients with Eagle syndrome.

Bilateral carotid dissection due to Eagle syndrome.

Eagle syndrome is defined as a collection of symptoms affecting the cervical and cranial regions, resulting from an elongated styloid process or ossified stylohyoid ligament encroaching on surrounding structures and causing a variety of symptoms. Classically, Eagle syndrome presents as neck, throat, or ear pain. Carotid artery dissection is a rare complication of Eagle syndrome. We report the case of a 40-year-old man who presented with bilateral internal carotid artery dissection secondary to pathological elongation of the styloid processes.

The External Carotid Artery and the Styloid Process.

BACKGROUND: The external carotid artery (ECA) is typically regarded as coursing between the styloid muscles to continue into the parotid space. The anatomical possibility of an ECA with an ascending parapharyngeal trajectory continuing posteriorly to an elongated styloid process (ESP), thus retrostyloid, to the parotid space is overlooked. It was, therefore, aimed to document the prevalence of this retrostyloid variant of the ECA's course. METHODS: We investigated a retrospective random cohort of 160 archived CT angiograms of 97 males and 63 females aged between 47 and 76. The presence of an ESP and the retrostyloid course of the ECA were bilaterally documented. RESULTS: An ESP was identified in 99/320 sides (30.94%), regardless of the ECA course. In the overall group, we obtained 35% null cases for the two variables on the right and 34.06% for the left. ESPs were identified in 8.75% on the right side and 10.31% on the left. The ECAs had retrostyloid courses in 6.25% on the right side and 5.63% on the left. Thus, of the 320 ECAs documented on both sides, 221 (69.06%) had no retrostyloid courses, and we did not identify any ESP in those cases. ESPs were detected in 19.06% of the sides but without retrostyloid ECAs, and retrostyloid courses of the ECAs were detected in 11.88%. CONCLUSIONS: The possibility of a retrostyloid course of the ECA should not be ignored. An ESP may misinform the surgeon about the main carotid artery located immediately deep to it.

Vascular variant of Eagle syndrome: a review.

Eagle syndrome is defined as an elongated styloid process (ESP) that compresses nearby vasculo-nervous structures. The vascular variant of Eagle syndrome can lead to neurological symptoms including syncope, transient ischemic attack, or stroke; however, it has also been associated with other atypical presentations, making its diagnosis challenging. This review aimed to depict the characteristics of patients with the symptomatic vascular variant of Eagle syndrome. The literature search identified 56 reported cases of vascular variants of Eagle syndrome, with a mean age at onset of 51 years (range: 15-85 years), and the male-to-female ratio was 2:4. The ESP was bilateral in 63% of the cases, and the mean length was 48 mm (range: 31-77 mm). Vascular complications were mostly represented by internal jugular vein (IVJ) stenosis (n = 28), followed by internal carotid artery (ICA) dissection (n = 15). Additionally, eight cases of ICA thrombosis and two cases of severe chronic stenosis of the ICA > 90% were reported. Vascular complications may lead to cerebral ischemia due to either a thromboembolic mechanism or, less frequently, reduced blood flow. Laminar cortical necrosis, as a cerebral complication of ICA compression, was exceptionally described in one case, and such an atypical clinical presentation may be regarded as a diagnostic pitfall.

Extracranial internal carotid artery-dissecting aneurysm having a re-entry tear and causing lower cranial nerve palsies treated with flow-diverting stent: A case report.

Background: Extracranial internal carotid artery (ICA)-dissecting aneurysms (DAs) rarely cause re-entry tears and lower cranial nerve palsies. The therapeutic strategies for these pathologies are not well established. This report presents a case of an extracranial ICA -DA with a re-entry tear that caused lower cranial nerve palsy. Case Description: A 60-year-old man presented with left neck pain, hoarseness, and dysphagia. Physical examination and laryngoscopy determined palsies of the left cranial nerves IX, X, and XII. Digital subtraction angiography (DSA) revealed a DA in the left extracranial ICA, and three-dimensional DSA showed entry and re-entry tears in the intimal flap. Flow-diverting stents (FDSs) were placed on the lesion that covered the entry and re-entry tears because the symptoms did not improve after five weeks of conservative treatment. A post-procedural angiogram indicated flow stagnation in the DA. Symptoms improved remarkably immediately after the procedure, and the aneurysm was almost completely occluded six months later. Conclusion: Herein, an extracranial ICA -DA with a re-entry tear that caused lower cranial nerve palsy did not improve after five weeks of conservative treatment. FDS placement promptly resolved the aneurysm and symptoms. Thus, FDS placement may be an effective treatment option for extracranial ICA-DAs with re-entry tears or lower cranial nerve palsies.