Computed Tomography Perfusion Can Guide Endovascular Therapy in Bilateral Carotid Artery Dissection

INTRODUCTION: Carotid artery dissection (CAD) is a major cause of stroke in those under age 45, accounting for around 20% of ischaemic events([1,2]). In the absence of known connective tissue disorders, most dissections are traumatic([2]). First-line management is comprised of antiplatelet or anticoagulation therapy, but many traumatic dissections progress despite this and carry the risk of long-term complications from embolism or stenosis([3]). We report a case of traumatic bilateral carotid dissection leading to progressive neurological symptoms and hypoperfusion on computed tomography perfusion (CTP), despite escalation in anticoagulation, which led to emergency carotid stenting. LEARNING POINTS: Carotid artery dissection should always be considered in young patients presenting with stroke. Most strokes are caused by emboli from the injured vessel but hypoperfusion, especially from bilateral dissections, can also cause stroke. Anticoagulation or antiplatelets are used as first-line therapy, though there are no randomised control trials to guide management. Failure of medical therapy can be common and endovascular therapy should be considered in these cases. Computed tomography perfusion (CTP) scanning can be useful because it highlights areas of ischaemic penumbra that may be salvageable through such intervention.