Optical Coherence Tomography for Cervical Artery Dissection

A 21-year-old female presented with acute-onset left-sided neck pain, severe occipital headache, and vomiting following a neck massage. Digital subtraction angiography (DSA) revealed long-segment stenosis (>15 mm) and a dissecting aneurysm in the V2 segment of the left vertebral artery (Fig 1A). Intravascular optical coherence tomography (OCT) provided unprecedented visualization of the dissection morphology: a mobile intimal flap, a fenestrated intramural hematoma (IMH) compressing the true lumen by 65%, and a 3.2 mm saccular dissecting aneurysm (Fig 1B–E, Video S1). The IMH exhibited heterogeneous signal intensity, suggesting acute-phase blood products. Three months of dual antiplatelet therapy (aspirin 100 mg + clopidogrel 75 mg daily) resulted in complete anatomical resolution on follow-up computed tomography angiography (CTA). Cervical artery dissection (CeAD) is a significant cause of stroke in young adults, arising from a tear or separation in the inner lining of a cervical artery, typically affecting the extracranial internal carotid or vertebral arteries.1 The preliminary application of high-resolution OCT in the diagnosis of CeAD, showing its utility and feasibility as an imaging method for evaluating the morphological features of dissection.2, 3 By delivering ultrahigh-resolution (10–20 μm) cross-sectional images, OCT surpasses conventional imaging techniques like CTA and magnetic resonance angiography (MRA) in delineating the intricate morphological hallmarks of CeAD. It enables direct visualization of the dissection plane between arterial wall layers (intima, media, adventitia) (Fig 1F), reliably identifying pathognomonic features such as intimal tears, double-lumen formation, IMH, and dissecting aneurysms. This capability proves especially critical in small-caliber arteries, including vertebral and intracranial vessels, where subtle flaps or hematomas may evade detection by lower-resolution modalities. During diagnostic angiography, OCT serves as a real-time decision-making tool. When angiography raises suspicion of dissection, OCT can immediately confirm the diagnosis by mapping the extent of the intimal tear and quantifying stenosis caused by IMH. Its ability to differentiate between the true and false lumen provides essential insights into hemodynamic consequences and guides therapeutic strategies. For instance, OCT aids in assessing the stability of dissection flaps: mobile or prolapsed flaps threatening vessel patency may warrant endovascular stenting, while stable lesions with contained IMH could be managed conservatively. Additionally, OCT's detailed characterization of dissecting aneurysms informs rupture risk stratification and monitoring protocols. The technique's clinical utility extends beyond diagnosis to mechanistic understanding. By revealing layer-specific injury patterns and hematoma propagation pathways, OCT enhances comprehension of CeAD pathophysiology. Despite challenges related to arterial access and procedural expertise, its unmatched resolution and dynamic assessment capabilities position OCT as an indispensable adjunct in the precision management of CeAD, bridging critical gaps in current imaging paradigms for this complex vascular disorder. We thank the patient for her consent to publish the case report. Guangxun Shen: Conceptualization; writing – original draft; writing – review and editing. Jingmin Zhao: Conceptualization; writing – review and editing. Ying Mao: Writing – review and editing; data curation. Guangxian Nan: Conceptualization; writing – original draft; writing – review and editing. Nothing to report. Video S1. Fenestrated vertebral artery dissection revealed by OCT. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.