title: Therapeutic and diagnostic implication of inadequate circle of willis in a patient with acute spontaneous bilateral internal carotid artery dissection: case report and review of the literature.
abstract: OBJECTIVE
  Emphasizing the therapeutic and diagnostic implications of concomitant inadequate collaterals from the circle of Willis in a rare case of spontaneous acute bilateral internal carotid artery dissection (BICAD) following 5 days of isolated rigorous cough (pertussis like).
  
  
  METHODS
  A 45-year-old male has been referred to our department with rapid neurological deterioration consisting of dysarthria and severe left hemiparesis following 5 days of isolated rigorous cough. CTA demonstrated BICAD, a tiny anterior communicating artery and no bilateral posterior communicating artery. The patient had no personal or familial risk factors. Infectious, traumatic, vascular and connective tissue diseases were ruled out.
  
  
  RESULTS
  Neurological deterioration persisted despite immediate provision of continuous 'full-heparinization' with concomitant rigorous control of blood pressure. Endovascular treatment consisting of bilateral stenting was undertaken. Ten days later, the patient was discharged with mild hemiparesis and resuming normal activity after 3 months.
  
  
  CONCLUSIONS
  BICAD with concomitant inadequate collaterals from the circle of Willis may predispose to hypoperfusion which might not respond to the usual conservative treatment prompting for flow reestablishment. Moreover, isolated rigorous cough can cause acute spontaneous BICAD even among patients without any risk factors.
authors.affiliation: Department of Neurosurgery and Interventional Neuroradiology Unit, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Mikael
authors.initials: M
authors.lastname: Levy
authors.forename: Esther
authors.initials: E
authors.lastname: Arfi-Levy
authors.forename: Shimon
authors.initials: S
authors.lastname: Maimon