Bilateral internal carotid artery dissection and occlusion in Eagle syndrome treated with emergency single-session bilateral carotid artery stenting: a case report

Abstract

Eagle syndrome (stylocarotid variant) is a rare but potentially life-threatening cause of internal carotid artery (ICA) dissection and ischemic stroke. Bilateral ICA dissection due to Eagle syndrome has been treated with both staged and single-session bilateral carotid stenting employed staged procedures. We report a patient in whom emergency single-session bilateral carotid artery stenting was performed for left ICA occlusion with contralateral subtotal occlusion and asymmetric collateral reserve, and describe serial imaging and clinical follow-up to 45.9 months. A 53-year-old male machinist without conventional vascular risk factors presented with a 4-day history of episodic right monocular visual loss and progressive left hemiparesis (NIHSS 3, mRS 2). He had used a pulse-type neck massage device daily for approximately 10 days before onset; symptoms were initially misattributed to cervical spondylosis. MRI-DWI demonstrated acute right subcortical watershed infarctions; MRA and CTA confirmed bilateral long-segment ICA dissection with double lumen signs and bilateral elongated styloid processes abutting both ICAs, fulfilling diagnostic criteria for Eagle syndrome. On hospital day four, the patient deteriorated to an in-hospital stroke (NIHSS 16, mRS 4); emergency DSA confirmed left ICA occlusion at the C1 segment and right ICA subtotal occlusion with preserved but severely attenuated antegrade flow, with asymmetric collateral reserve. Emergency single-session bilateral carotid stenting was performed (70 min from deterioration to puncture), achieving mTICI 3 bilaterally. NIHSS improved to 3 with full right-limb motor recovery at 3 h; NIHSS was 2 and mRS was 2 at discharge on day 14. Serial follow-up to 45.9 months confirmed sustained bilateral stent patency without in-stent restenosis, stent fracture or recurrent ischemia; at the most recent assessment NIHSS was 1 and mRS 1. Emergency single-session bilateral carotid artery stenting was feasible in Eagle syndrome-related bilateral ICA dissection with unilateral occlusion, contralateral subtotal occlusion and asymmetric collateral reserve, and was followed by early neurological improvement and bilateral stent patency at 45.9 months. Whether single-session treatment is preferable to a staged strategy cannot be determined from a single case. Repetitive pulse-type neck massage may have contributed to the dissections in this anatomically predisposed patients, and persistent styloid-stent proximity warrants continued surveillance.