INTRODUCTION

Intracranial artery dissections are rare diseases, usually associated with subarachnoid hemorrhage. Rarer presentations are ischemic stroke and isolated headache. The V4 vertebral artery (VA) is one of the most frequent location for intracranial dissection.

METHODS

We are presenting four cases of V4 VA dissections without hemorrhagic presentation from a single center from 2023 to 2025 Two of the presented patients had an ischemic stroke and two had isolated headache. All patients were admitted to the Emergency Department and underwent non contrast computed tomography (NCCT) and CT angiography (CTA) for diagnostic purposes. The diagnosis in V4 VA dissection was confirmed by Magnetic Resonance Imaging (MRI) and mural hematoma and/or intimal flap were identified using vessel wall imaging (VWI).

DISCUSSION

Intracranial dissections and dissecting aneurysms can present with ischemic or hemorrhagic complications. Imaging, including CTA, MRA, and HR-VWI, is essential for diagnosis, identifying features like fusiform dilation, stenosis, intramural hematomas, and intimal flaps. Dissections can heal in various ways, but persistent aneurysmal changes may increase stroke risk. Prognosis varies, with ischemic cases prone to recurrence and hemorrhagic cases at higher risk for rebleeding. No standardized treatment exists, though antithrombotic therapy and intravenous thrombolysis are used based on limited data.

CONCLUSIONS

Intracranial VA dissections without subarachnoid hemorrhage are rare diseases and without a dedicated multidisciplinary pathway of care might be missed or remain underdiagnosed, preventing the design of therapeutic studies.