To describe a case of exclusive bilateral common carotid artery dissection presenting as delayed cerebral ischemia after a motor vehicle accident (MVA).

Dissections in the cervico-cerebral vessels occur most frequently in the cervical internal carotid arteries and the intradural vertebral arteries. Unilateral common carotid artery dissections are generally associated with penetrating or direct blunt trauma to the neck, particularly due to hanging or strangulation, or they can occur as an extension of an aortic dissection, or even “spontaneously,” without a defined inciting event. Exclusive bilateral common carotid artery dissection is an extremely rare occurrence of unknown incidence.  

Case report and literature review.

A middle-aged woman presented to the emergency department of our tertiary trauma center with global aphasia, left-sided gaze deviation, and right-sided weakness 4 days after a MVA. Initial National Institutes of Health Stroke Scale (NIHSS) was 13, and the patient received intravenous tissue plasminogen activator (tPA) with improved NIHSS to a 4 post tPA.  No direct neck trauma was reported by the patient nor any clinical signs were found on physical examination.

Imaging with computed tomography angiography (CTA) revealed focal linear defects within the distal bilateral common carotid arteries consistent with dissection, along with distal arterial thrombi in the M3 and M4 segments of the left middle cerebral artery (MCA). Magnetic Resonance Imaging of the brain showed multiple separate foci of acute ischemic infarction in the left MCA distribution. The patient’s exam improved to NIHSS of 0.

Common carotid artery dissection should be on the differential in patients presenting with a recent history of MVA and signs of focal cerebral ischemia. This report highlights an atypical presentation of simultaneous exclusive bilateral common carotid dissection without direct neck trauma and with the delayed onset of left MCA artery-to-artery embolism and ischemic stroke.