Presentation A 22 year old male with no comorbidities presented with a witnessed collapse, dysconjugate eye movements, dysarthria, right-sided head and neck (H&N) pain with contralateral hemiplegia and facial droop (NIHSS 14).

CTH and angio showed right ICA dissection just beyond its origin causing complete occlusion. A thrombus was present at the right M1. There was partial patency in this region and in distal MCA branches with collateral supply from the ACAs-AComm.

Intervention Thrombolysis was performed but terminated with 1 ml tPA remaining due to patient deterioration (NIHSS 20). Repeat CTH showed evolving right middle and inferior frontal gyri infarcts.

Mechanical thrombectomy was performed and aspirated with successful reperfusion of the MCA. The ICA was stented with overlapping Precise 8x40 mm and 8x30 mm. Good flow was demonstrated. Patient was transferred to HDU for monitoring.

Post-procedural CTH and CT angio carotid, aortic arch and intracranial region demonstrated stent patency with no intraluminal thrombus and good flow in the right ICA. Imaging also showed right ACA infarct, evolution of right anterior MCA ischaemia and an established infarct in the right caudate nucleus.

Follow-up At neurology follow-up, he was neurologically intact and able to communicate. He had residual H&N pain, short term memory impairment, intermittent lightheadedness and insomnia. He was prescribed pregabalin and naproxen and declined occipital nerve block.

Neurovascular MDT identified a fractured elongated styloid process alongside the dissection, suggesting stylocarotid (Eagle’s) syndrome as a mechanism of injury. An ENT consultation was sought. Styloidectomy was explained and offered but patient refused further surgical intervention.

Disclosure of Interest Nothing to disclose