C123 Eagle syndrome: a case of carotid compression from elongated styloid process with distal embolic occlusions in middle cerebral arterial (mca) territory

<h3>Introduction</h3> Eagle’s syndrome (first described by American otorhinolaryngologist Dr. Watt Weems Eagle) is a rare condition involving styloid process elongation, potentially causing vascular compression and ischemic stroke. Its diagnosis and management remain challenging, particularly when the stroke aetiology is unclear. <h3>Case Description</h3> We report a patient in 60s presented with sudden right-sided weakness and aphasia. Computed tomography (CT) scan with angiography protocol revealed mild focal stenosis at the left cervical ICA due to extrinsic compression by an elongated styloid process and left middle cerebral artery (MCA) territorial ischaemic stroke. Intravenous thrombolysis with alteplase (rTPA) was given. The patient was sent for endovascular mechanical thrombectomy (EVT) due to an initial impression of proximal medium-sized vessel occlusion (MeVO). After angiographic assessment, EVT was aborted due to mostly distal vessel occlusions (DVOs) in the left MCA cortical branches. Diagnostic angiography also demonstrated mid-cervical ICA narrowing from left styloid process compression. Multidisciplinary discussion identified eagle syndrome as one of the probable embolic sources. The patient was then discharged on apixaban for atrial fibrillation, and referred to the neurosurgeons for consideration of left styloidectomy with carotid artery decompression. <h3>Conclusions</h3> This case highlights Eagle’s syndrome as a rare, surgically correctable cause of stroke. Recognition of this condition is crucial when evaluating atypical stroke mechanisms, especially in the presence of ICA compression without large vessel occlusion. Surgical intervention can be considered to mitigate recurrent embolic risk. <h3>Conflict of Interest</h3> No