Spontaneous recanalization of pediatric internal carotid artery dissection during aspirin monotherapy: a retrospective case series

Purpose Internal carotid artery (ICA) dissection is an increasingly recognized cause of arterial ischemic stroke (AIS) in children, but optimal management strategies remain uncertain. While anticoagulation or antiplatelet therapy is commonly employed, data on radiographic outcomes and vessel recanalization rates are limited. The objective of this study was to describe the clinical and radiographic outcomes of children with ICA dissection-related AIS who received aspirin monotherapy for secondary prevention. Methods We retrospectively reviewed five consecutive pediatric patients with acute AIS secondary to ICA dissection treated at our institution between 2018 and 2025. All patients received aspirin monotherapy (3–5 mg/kg/day) initiated at diagnosis. Clinical presentations, neuroimaging findings (MRI/MRA, DSA, vessel wall imaging), laboratory evaluations, and follow-up imaging were analyzed. The primary outcome was angiographic vessel recanalization on follow-up imaging. Results Three patients had right-sided and two had left-sided intracranial ICA dissections. Two cases were associated with definite trauma, while three cases were spontaneous. All patients presented with acute hemiparesis, and two presented with seizures. Laboratory findings ruled out the diagnosis of large-vessel vasculitis. Follow-up vascular imaging (MRI/MRA) performed at discharge demonstrated complete recanalization of the affected ICA in all five patients. All patients achieved favorable neurological outcomes with resolution or significant improvement of deficits. Conclusion This case series demonstrates that aspirin monotherapy may be associated with complete vascular recanalization and favorable clinical outcomes in pediatric ICA dissection, including both traumatic and spontaneous cases. It suggests that complete vessel recanalization may be more common in children than previously recognized.