Vascular eagle syndrome occurs when an elongated styloid process causes impingement to a carotid artery. Four percent of the general population have an elongated styloid process; only four percent are symptomatic. Clinical manifestations occur due to angulation in the middle or end of the styloid, in which turning the head might compress the carotid artery or even tear the vessel itself.  Some manifestations include syncope from irritation of the sympathetic plexus, restriction in blood flow, transient ischemic attack, and carotid dissection. 

This is an 82- year-old man who presented due to sudden onset of left-sided hemiparesis, urinary incontinence, and aphasia upon awakening. His medical history was significant for recent atrial fibrillation with a pacemaker (not on anticoagulation), hypertension, and hyperlipidemia.

Neurological examination revealed left pronator drift, hemisensory neglect on simultaneous tactile stimulation, and a positive left plantar reflex. Computed tomography angiogram (CTA) head and neck revealed a short segment nonflow-limiting dissection of the right mid-cervical internal carotid artery. Magnetic resonance imaging (MRI) of the brain showed multiple areas of cortical and subcortical hyperintense diffusion and T2 foci involving the right frontoparietal and insular cortex most consistent with late acute infarct. Further review showed an elongated styloid process impinging on the right carotid artery. 

Due to this patient's age and risk factors, he was not a candidate for surgical intervention. He was started on a heparin drip and bridged to warfarin for secondary stroke prevention for both extracranial cervical dissection and concurrent atrial fibrillation. Stent placement at a later date would be considered if he failed medical therapy.

An elongated styloid process should be considered in an atraumatic, symptomatic cervical dissection presenting with ischemic infarcts. There is limited data regarding management of vascular eagle syndrome and should be studied further to compare medical management versus surgical intervention.