If an elongated styloid process causes a dissecting internal carotid artery aneurysm, surgical resection is indicated

We read with interest the article by Izutsu et al., about a 60-year-old man who developed acute neck pain, dysphagia, hoarseness, and tongue deviation to the left after turning his head to the right and who subsequently developed a dissecting aneurysm (DA) of the left extracranial internal carotid artery (ICA). [2]e development of the DA was attributed to an elongated left styloid process. [2]Conservative treatment with therapeutic heparin (for 1 week) and dual antiplatelet therapy with acetylsalicylic acid and clopidogrel (for 4 weeks) was ineffective, so the patient underwent elective stenting of the left ICA with a flow diverter stent (FDS), resulting in almost complete resolution of symptoms and recovery. [2]e study is impressive, but some points require further discussion.e first point is that the impairment of the lower cranial nerves in patients with DA of the ICA may not be explained only by the impairment of the lower cranial nerves IX, X, and XII through direct contact with the aneurysm or occlusion of nutrient arteries. [2]Impairment of the lower cranial nerve can also be explained by insufficient perfusion of the basilar artery through both vertebral arteries or through the circle of Wilisii in case of retrograde filling.erefore, we should know whether the vertebral arteries were orthogradely perfused or whether they were stenotic or occluded on carotid ultrasound.Did the patient have subclavian steal syndrome?Was the carotid ultrasound normal, or were there morphological or functional abnormalities?e second point relates to the outcome of the FDS placement.It is stated that the patient "improved remarkable" immediately after the procedure. [2]However, it does not specify which symptoms improved.e patient was admitted with neck pain, hoarseness, difficulty swallowing, and tongue deviation.Which of these symptoms improved or disappeared completely, and which persisted?e third point is that it is not understandable why the elongated styloid process was not resected since it was considered responsible for the development of DA.Long styloid processes have been described before as the cause of an ICA aneurysm (Eagle syndrome) [1], and in some of these patients, resection of the elongated styloid process was beneficial [4] or prevented the recurrence of the aneurysm. [3] A fourth point is that it was not stated how many days before admission the symptoms began.Did the patient experience neck pain, difficulty swallowing, tongue deviation, and hoarseness the day before admission or earlier?A fifth point is that some essential information is missing.What is the reason why digital subtraction angiography and magnetic resonance angiogram were not performed under a provocative posture www.surgicalneurologyint.