spontaneous cerebral arterial dissections ( cad ) are more frequent among young patients ( 40 - 45 years of age [ 1 , 2 ] ) , of which the internal carotid artery ( ica ) are one of the major sites for dissections . spontaneous cads are generally related to : connective tissue diseases [ fibromuscular dysplasia   in up to 15 - 50% of bilateral internal carotid artery dissection ( bicad ) , ehlers - danlos syndrome , marfan syndrome , polycystic kidney disease , osteogenesis imperfecta , and systemic lupus erythematosus ] and/or preceding infectious diseases . internal carotid artery dissections ( icads ) may account for up to 2.5% of all first strokes and are responsible for 5 - 20% [ 4 , 6 ] of all ischemic strokes ( the commoner type among young patients ) in adults . among all icad , bicad is as frequent as 5 - 21% despite possible initial presentation with unilateral symptoms [ 7 , 8 , 9 ] . icad without subarachnoid hemorrhage ( sah ) are more frequent in younger patients ( < 30 years of age ) , while vertebro - basilar dissections with sah are more common in older patients ( > 30 years of age ) . common presenting features of spontaneous icad include : headache , ipsilateral neck pain , incomplete horner 's syndrome ( ptosis and myosis ) , bruits , transient ischemic attack / cerebrovascular accident signs as amaurosis fugax , syncope , encephalopathy and focal signs . these might be explained by either embolic event and/or reduced flow distal to the dissected segment and/or concurrent sah . most cases can be diagnosed by mri , mra , and cta ; however , angiography is still needed for some cases . treatment consists of anticoagulation / antiplatelet therapy , while endovascular or surgical interventions generally are indicated for intradural cases with sah or when persisting clinical deterioration is noted despite anticoagulation . a case of simultaneous spontaneous acute bicad concomitant with inadequate collateral blood supply from the circle of willis , preceded by isolated rigorous cough in a patient without any risk factor or infectious disease was not reported previously and is hereby presented , emphasizing the therapeutic implication of these concomitant findings . a 45-year - old man who suffered from paroxysmal severe nonproductive cough lasting for 5 days before his admission was referred to our emergency room from another hospital . family and personal history were noncontributory . by the fifth day a bicad with severe stenosis was demonstrated on cta . a tiny anterior communicating artery ( acom ) with no bilateral posterior communicating artery ( pcom ) , immediate administration of heparin was initiated . on his arrival to our emergency room , the patient 's neurological findings consisted of dysarthria , left hemiparesis ( hand pronation ) and bilateral babinski signs . his blood tests were normal except for prolonged ptt ( > 120 s ) due to previous heparin administration . the patient was transferred to the neurointensive care unit for the continuation of heparin treatment , maintaining a ptt range of 60 - 70 s with concomitant rigorous regulation of blood pressure ( systolic 110 - 140 mm hg ) . persisting clinical deterioration for the next following hours despite anticoagulation was noted : the patient developed neglect and became hemiplegic . he was taken to the angiography room : under general anesthesia four vessels angiography was performed demonstrating near complete occlusion of the right ica and severe stenosis of the left ica due to bicad in the cervical area ( fig . stenting of both ica ( two stents each side ) was performed restoring flow bilaterally with normal parenchymal blush ( fig . 3 ) . a small acom with mild flow from left to right was demonstrated , while restoring the flow in the left hemisphere . following stenting , the patient received iib / iiia - antagonist further converted to clopidogrel and aspirin by the next day , and heparin treatment was discontinued . two days following stenting , a subcortical small watershade infarct was demonstrated on a ct ( in the para - midline aca - mca passage ) further supporting that hypoperfusion was the underlying cause ( fig . a thorough workup for venous - arterial and connective tissue diseases , both personal and familial , was noncontributory . gradual improvement was noted and the patient was discharged after 10 days , showing further improvement : fully conscious , able to stand and walk with some support , less prominent neglect and dysarthria . he was referred to further rehabilitation and resumed normal activity as a physician by 3 months . antiplatelet ( aspirin and plavix for 6 months ) and neuroimaging were prescribed on discharge . the patient did not show any new neurological event until now , a year from treatment . icad can account for 10 - 25% of strokes in young patients [ 2 , 8 , 10 , 11 , 12 ] and is considered as one of the main causes for stroke recurrence . among 1 - 5% of all spontaneous icad cases , a heritable connective - tissue disorder can by identifiable and 5% may have one family member with spontaneous dissection of various arteries including the aorta or its main branches [ 13 , 14 , 15 , 16 ] . reported a case of a previously healthy 29-year - old woman with bilateral vertebral artery dissection ( vad ) and icad associated with multiple aneurysms ( saccular and fusiform ) that resolved spontaneously by 6 months . the natural course of icad seems to be composed of an acute phase during which conservative or more rarely endovascular / surgical treatments are undertaken followed by a chronic phase during which a recanalization occurs in the majority of patients during the following 6 months . some have reported that delayed recanalization can occur after 16 months as well , a fact that might prompt individual consideration regarding the time for anticoagulation / antiplatelet therapy . recently , schwartz et al .   reported that among 177 young patients , 8.5% had recurrent ischemic events unrelated to the type of antithrombotic agent ( others have reported a recurrence of 15% ) and 1.1% had recurrent dissections ( others have reported a recurrence of 3 - 8% after longer clinical follow - up of up to 7.4 years [ 21 , 22 , 23 ] ) . reported a case of an adult male with cad and massive right hemisphere infarct during the course of pertussis . this patient as ours had no predisposing risk factors ( htn , dm , dyslipidemias , connective tissue diseases or smoking ) . their patient required 6 weeks of acute care hospitalization during which craniectomy and temporal lobe resection were needed followed by prolonged rehabilitation . preceding respiratory tract infection has been proposed as a possible risk factor for icad supported by the fact that the occurrence of icad peaks during the fall [ 24 , 25 , 26 ] . [ 24 , 25 ] reported that patients with cad had a higher prevalence of infections compared with controls ( 62 vs. 22% ) , while excluding mechanical factors as cough , sneezing and vomiting .  mechanical cough ( naming , unrelated to infectious diseases ) causing dissections is reported in just few case studies describing vad rather than cad . reported a case of a 45-year - old man who developed wallenberg 's syndrome due to vad following severe cough . herr et al .   reported a case of a man with vad presenting with signs of posterior - inferior cerebellar artery territory stroke , following severe cough . we hereby describe a unique case of a patient with rigorous noninfectious cough followed by acute bilateral spontaneous dissection of the anterior rather than posterior circulation and with concomitant inadequate collaterals from the circle of willis . it is generally accepted that most of the icad cases proceed to recanalization within 6 months after dissection . progression of disease is believed to start a few days post - dissection and can take up to 6 months . the treatment for icad consists of three possible approaches [ 29 , 30 ] : conservative , endovascular or surgical . conservative treatment consists of two steps : an acute anticoagulation with heparin followed by secondary prophylaxis by oral anticoagulation / antiplatelet that normally is sufficient for 3 - 12 months ( however , delayed recanalization as described by vicenzini et al .   can prolong this period ) . although anticoagulation is recommended , the question whether warfarin or aspirin is more effective for recanalization is yet debatable . once recanalization is documented and arterial flow is reestablished , anticoagulation continuation should be reconsidered . the patient must therefore undergo neuroimaging follow - up ( mra and mri ) during the following 3 - 6 months and avoid forceful efforts . surgical and/or endovascular treatments are indicated for spontaneous icad with either persisting severe stenosis ( mainly for intradural icad ) , progressive neurologic symptoms despite conservative treatment ( as in our patient ) or bicad that result in severe cerebral hemodynamic impairment . patients with icad and sah require either surgery or endovascular treatment due to recurrence tendency . to our knowledge , this represents the first reported case of spontaneous bicad following isolated rigorous cough with inadequate circle of willis that seemed to have important therapeutic implications . bicad with concomitant inadequate circle of willis ( tiny acom with no pcom as in our patient ) can prone for hypoperfusion which might not respond to conservative treatment and can lead to rapid deterioration and therefore prompt to earlier endovascular intervention as was done in this case . rigorous cough can solely cause acute spontaneous bicad that should be suspected even in a patient with no other risk factors as in our patient . we would therefore recommend a thorough evaluation of the collateral flow in patients with uni-/bilateral icad , which might facilitate the decision in whom to perform an early arterial flow reestablishment .
background and purposeemphasizing the therapeutic and diagnostic implications of concomitant inadequate collaterals from the circle of willis in a rare case of spontaneous acute bilateral internal carotid artery dissection ( bicad ) following 5 days of isolated rigorous cough ( pertussis like).case descriptiona 45-year - old male has been referred to our department with rapid neurological deterioration consisting of dysarthria and severe left hemiparesis following 5 days of isolated rigorous cough . 
 cta demonstrated bicad , a tiny anterior communicating artery and no bilateral posterior communicating artery . 
 the patient had no personal or familial risk factors . infectious , traumatic , vascular and connective tissue diseases were ruled out.resultsneurological deterioration persisted despite immediate provision of continuous 
 full - heparinization with concomitant rigorous control of blood pressure . 
 endovascular treatment consisting of bilateral stenting was undertaken . 
 ten days later , the patient was discharged with mild hemiparesis and resuming normal activity after 3 months.conclusionsbicad with concomitant inadequate collaterals from the circle of willis may predispose to hypoperfusion which might not respond to the usual conservative treatment prompting for flow reestablishment . moreover 
 , isolated rigorous cough can cause acute spontaneous bicad even among patients without any risk factors .