Clinical Outcomes and Management of Intracranial Arterial Dissection Revealed in Case Series

Introduction Intracranial arterial dissection (IAD) is a rare and underrecognized cause of ischemic stroke and subarachnoid hemorrhage (SAH), particularly in younger patients. Reported outcomes highlight its severity, with ∼50‐60% developing SAH and 30‐78% experiencing ischemic events. Despite these risks, the low prevalence of IAD has limited robust data and evidence‐based guidelines. In this case series, we present six patients with IAD, detailing their clinical course, management strategies, and outcomes. By elaborating on their treatment and prognosis, we aim to contribute to the understanding of therapeutic decision‐making in this uncommon but high‐stakes condition. Materials None Methods This case series describes six patients with IAD identified at Hartford Hospital between January 2021 and June 2025. Results In our cohort, the patient population ranged in age from 20 to 65 years (4 female, 2 male). Three cases involved the anterior circulation (all M1 segments of the MCA), and three involved the posterior circulation (all V4 segments of the vertebral artery, with one extending into the basilar artery). Four patients presented with headaches, and two had NIHSS scores >6. Diagnosis was confirmed with DSA (n=3), CTA (n=2), and MRA (n=1). One patient received thrombolytic treatment for transient focal symptoms but subsequently improved, with no infarct identified; symptoms were determined to be pressure dependent. All patients were initially treated with dual antiplatelet therapy. Two patients worsened during hospitalization: one with anterior circulation IAD developed a new thrombus and was switched to anticoagulation, while one with posterior circulation IAD experienced extension into the basilar artery and worsening infarct, requiring stent placement with TICI 3 reperfusion. On follow‐up, among the anterior circulation cases, one patient had worsening stenosis but remained asymptomatic and was managed conservatively, one showed resolution, and one had stable stenosis with improved collaterals. In the posterior circulation cases, one patient improved on anticoagulation, one developed atresia of the right vertebral artery due to lack of demand in the infarcted area, and the stented patient maintained stable flow. Conclusion In our series, medical management was effective for most patients, leading to stable or improved vessel caliber and favorable outcomes. Progression, although uncommon, required urgent endovascular intervention, underscoring the importance of vigilant monitoring. Headaches often present as a prodromal symptom, emphasizing their diagnostic significance. Intensive medical therapy may be considered in select cases to optimize outcomes. Thus, while medical therapy remains the cornerstone, individualized care and timely intervention are essential to prevent complications.