Snapshot A 34-year-old woman presents to the emergency department with constant and severe right-sided headaches. One day prior to presentation, she was in a minor motor vehicle accident where her head jerked forward. She has also noticed mild eye-lid drooping earlier in the day. She smokes approximately 2-3 cigarettes per day. On physical exam, she has right-sided ptosis and miosis without anhydrosis. A non-contrast CT scan and CT angiography is performed, which demonstrates a tapered stenosis of the internal carotid artery and an intimal flap. Introduction Definition intimal tear of a cervical artery cervical arteries include carotid and vertebral arteries Epidemiology Risk factors trauma to the neck ETIOLOGY Pathogenesis an intimal tear of a cervical artery leads to an intramural hematoma, which results in stenosis occlusion aneurysm Presentation Classic triad one-sided head, neck, or facial pain (most common) partial Horner syndrome with internal carotid involvement which leads to miosis and ptosis there is no anhydrosis because the sympathetic fibers that are involved in facial sweating and vasodilation branch off of the oculosympathetic pathway at the superior cervical ganglion to course with the external carotid artery cerebral or retinal ischemia Symptoms symptoms secondary to stroke such as numbness weakness transient monocular blindness (amaurosis fugax) pulsatile tinnitus Physical exam physical exam findings secondary to stroke such as ataxia weakness aphasia Imaging Magnetic resonance angiography indication preferred imaging modality in the evaluation of cervical artery dissection CT angiography can also be used with relatively similar sensitivity and specificity findings hyperintense crescent-shaped rim and decreased lumen tapered stenosis or occlusion dissecting aneurysm Differential Migraine differentiating factor motor deficits are not typically seen in migraine headaches Treatment Medical tPA indication used in the acute ischemic stroke period in patients with extracranial cervical artery dissection antithrombotic or antiplatelet therapy indication depends on the type of cervical dissection Operative endovascular or surgical repair indication typically used in patients with recurrent ischemia even though they were treated with appropriate medical therapy Complications Ischemic stroke Prognosis Unfavorable factors cerebral ischemia increased age arterial occlusion