Images From Headache Spontaneous Bilateral Internal Carotid Artery Dissection Presenting With Right Hemifacial Pain Marco Luigetti, MD; Tommaso Bartalena, MD; Emanuele Pravatà, MD; Alessandro Cianfoni, MD A 66-year-old man was admitted to our depart- ment to investigate a 4-day history of right facial pain. Blood pressure was 180/90 mm Hg. Neurologi- cal examination and nonenhanced brain–computed tomography (CT) were unremarkable. The pain was confined to right hemiface, involving eye, cheek, and mouth, without a typical trunk nerve distribution. The patient was admitted and an antihypertensive therapy was started. Because of pain persistence, a brain mag- netic resonance imaging (MRI) and magnetic reso- nance (MR) angiography was obtained, revealing bilateral distal cervical nonocclusive internal carotid artery dissection (ICAD) (Figure).The MRI features of the mural hematoma suggested metachronous ICAD, with the right ICAD being more recent (Figure B,C). Extensive laboratory studies proved normal, including screening for systemic autoimmune disorders and thrombophilic conditions. Clinical visit and cardiological evaluation ruled out vascular con- ditions as fibromuscular dysplasia or Marfan syn- drome. No cervical traumas or manipulations were reported. CT angiography of the neck vasculature confirmed the bilateral ICAD and showed the residual patency of the true lumen. Antiplatelet treat- ment was started, and the patient was discharged 3 days later. Headache resolved progressively in the following weeks. COMMENT Cervical-artery dissections are defined by the presence of a mural hematoma located in the arterial wall under an intimal flap. 1 Although dissections have been reported to occur more frequently in the internal carotid arteries, they can also involve the vertebral arteries. 1,2 Many risk factors have been suggested, including traumas or manipulation to the neck, migraine, infection, hyperhomocysteinemia, and poly- morphism of methylenetetrahydrofolate reductase gene. Face and neck pain are common and suggestive symptoms of cervical artery dissection and sometimes may represent the only clinical manifestation. 1,2 Our patient presented with pain confined to right hemiface. Generally, ICAD presents with headache associated with cervical pain and might be complicated by ischemic stroke or transient ischemic attack. In our case, brain MRI did not reveal acute/subacute paren- chymal ischemic changes, while MRI and CT angiog- raphy revealed a bilateral ICAD. Furthermore, the MRI features of the intramural hematomas suggested a more recent right dissection and a previous left dissection that was apparently asymptomatic. The possibility of spontaneous bilateral ICAD has been already reported. 2,3 Probably, the right dissection involving the intracranial segment of the artery was responsible of pain because of the anatomical rapport with trigeminal nerve, as described for Raeder’s From the Department of Neurology, Catholic University of Sacred Heart, Rome, Italy (M. Luigetti); Department of Radi- ology, Pol. Zappi Bartalena, Imola, Italy (T. Bartalena); Insti- tute of Radiology, Catholic University of Sacred Heart, Rome, Italy (E. Pravatà); Neuroradiology Section, Radiology Depart- ment, Medical University of South Carolina, Charleston, SC, USA (A. Cianfoni); Neuroradiology – Neurocenter of Italian Switzerland, Lugano, Switzerland (A. Cianfoni). Conflict of Interest: The authors report no conflicts of interest. ISSN 0017-8748 doi: 10.1111/j.1526-4610.2012.02225.x Published by Wiley Periodicals, Inc. Headache © 2012 American Headache Society 1574