BILATERAL INTERNAL CAROTID ARTERY DISSECTION WITH CONFUSION

Bilateral internal carotid artery (ICA) dissections are rare. Typical clinical presentation includes cerebral ischaemia, neck/headache, Horner9s syndrome & pulsatile tinnitus1. We present a forty-two year old right-handed man admitted to hospital with a ten day gradual onset headache, altered taste, widespread cognitive impairments, horizontal diplopia and a right Horner9s syndrome. There was no history of trauma. Brain magnetic resonance imaging revealed multiple small embolic infarcts in carotid territories of both cerebral hemispheres. Computed tomography angiogram (CTA) of intracranial and extracranial vessels revealed occlusion of the left ICA and attenuation of the right ICA below the skull base. Symptoms resolved within 3–5 days of starting sub-cutaneous low molecular weight heparin and he was then anticoagulated with warfarin for six months. Repeat CTA at 4 months showed persisting complete left ICA occlusion but complete recanalisation of the right ICA. This is the first description of cognitive changes following bilateral ICA artery dissections. Whilst ICA dissection presentations are usually explained by embolic phenomena or local effects upon ICA walls, the mechanism here is probably due to cerebral hypoperfusion. Cognitive assessment should be performed in all patients presenting with ICA dissection especially when it is bilateral.