To evaluate the risk of stroke with common carotid artery(CCA) dissection. We report a rare case of spontaneous and isolated CCA dissection presenting with small left middle cerebral artery(MCA) territory ischemic strokes. 

Common Carotid artery dissection is a rare entity, that typically occurs in the setting of trauma, procedures, or the direct extension of an aortic dissection. Interestingly, isolated and spontaneous cases of CCA dissection, as in our case, are extremely rare. 

A 78-year-old gentleman with a history of atherosclerotic risk factors, paroxysmal atrial fibrillation on apixaban, and two previous episodes of transient ischemic attacks (TIA) presented with right-sided numbness and weakness. On examination, the patient had a right upper extremity pronator drift and an NIHSS of 1. 

Computed Tomography (CT)-Scan of the brain showed no acute intracranial abnormalities. However, Magnetic Resonance Imaging (MRI) revealed small left hemispheric infarcts in the MCA territory. CT-Angiography showed complete or near complete long segment occlusion of the left CCA shortly after its origin with a double lumen sign concerning for left CCA dissection complicated by complete left internal carotid artery (ICA) occlusion.

The patient was started on heparin drip for the initial 48 hours, which was then changed to apixaban, and was discharged on life-long apixaban and aspirin 81 mg daily for 3 months.