Spontaneous Unruptured Middle Cerebral Artery Dissection Presenting With Ischemia: Conservative Management and Rescue Endovascular Intervention

Spontaneous middle cerebral artery (MCA) dissection is a rare cause of ischemic stroke. Due to the lack of established guidelines, management strategies, ranging from conservative medical therapy to endovascular reconstruction, remain controversial. In Case 1, a 53-year-old woman presented with acute left upper limb paresis. Imaging revealed an infarct in the right MCA territory and angiographic features of dissection. She was treated conservatively with dual antiplatelet therapy. Her symptoms resolved, and follow-up imaging at 10 weeks demonstrated spontaneous angiographic healing of the vessel. In contrast, Case 2 involved a 72-year-old man who presented with right upper limb weakness due to left MCA dissection. Initial conservative management with antiplatelet therapy was insufficient; the patient experienced neurological deterioration with expanding infarction on day 5. Emergent endovascular reconstruction using a Wingspan stent (Stryker Neurovascular, Fremont, CA, USA) was performed. The procedure successfully stabilized the dissection, improved distal perfusion, and halted further neurological decline. These two cases suggest that conservative management may be reasonable in selected clinically stable patients with spontaneous unruptured ischemic MCA dissection, whereas rescue endovascular stenting may be considered in patients with neurological worsening and imaging progression despite medical therapy. Because this report includes only two cases, these observations should be interpreted cautiously.