Contralateral vertebral artery dissection after an unprecedented 14-year interval with a persistent intimal flap: A case report

Background: Bilateral vertebral artery dissection (VAD) is infrequent, and when it occurs, both sides typically dissect simultaneously or within days to weeks. Contralateral dissection after more than 1 year is extremely rare, with previously reported intervals frequently ranging from months to several years. This case demonstrates an unprecedented 14-year interval, highlighting the significance of extended surveillance. Case Description: A 55-year-old male with right VAD at 41 years old developed sudden left occipital headache and neck pain. His initial dissection had been conservatively managed with antihypertensive therapy and annual imaging. Despite a 14-year radiographic stability and maintained patency, high-resolution imaging consistently revealed a persistent intimal flap at the original site. New imaging confirmed left VAD with intimal flap and intramural hematoma. Workup for underlying arteriopathy was negative. Symptoms resolved with conservative management. Conclusion: This case describes contralateral VAD developing after an extraordinary 14-year interval, the longest reported to date. A persistent intimal flap was observed at the original site despite radiographic stability. While a causal relationship cannot be established from a single case, this observation raises the hypothesis that residual structural abnormalities may be associated with incomplete arterial healing. This report highlights that late contralateral recurrence is possible and suggests that imaging assessment of arterial wall integrity, in addition to luminal patency, may merit further investigation.