A 43-year-old female patient with migraines presented with rightsided headaches, jaw and ear pain, tongue and uvula deviation, right arm weakness, and dysphagia of solids and liquids resulting in a 7pound weight loss. Neurologic examination included serologic and cerebrospinal fluid evaluation, which ruled out infectious, inflammatory, and paraneoplastic diseases. Magnetic resonance imaging of the brain and computed tomography angiography of the head and neck ruled out cerebrovascular accident and vasculitis. The single abnormality was the distal internal carotid artery (ICA) in the parapharyngeal space (PPS). She was found to have bilateral ICA dissections with pseudoaneurysm (PSA), the left (11 mm in diameter) larger than the right (9 mm in diameter; A). A three-dimensional reconstruction of the computed tomography angiogram was obtained, and this demonstrated right ICA PSA impingement of the roots of cranial nerves IX, X, XI, and XII, symptoms known as the Collet-Sicard syndrome (B/Cover). Our diagnosis for its cause is fibromuscular dysplasia. The patient was treated empirically with prednisone, which worsened her symptoms. Therefore, she underwent placement of a Pipeline embolization device (PED; Medtronic, Minneapolis, Minn) into the right distal ICA (C). This PED stent is a flexible meshlike, bimetallic 48-strand braided construction that provides flow diversion and reduction of flow within aneurysms, which will then thrombose, approved for intracranial aneurysms. She was discharged from the hospital 2 days after this intervention on dual antiplatelet therapy (aspirin and clopidogrel) for 6 months. The patient noticed improvement within the first week of intervention and complete resolution of all symptoms by 1 month. Diagnostic angiography at the 2-month mark demonstrated an excellent result (D).Cranial nerve palsies due to lesions of the ICA are extremely rare. However, when they occur, fibromuscular dysplasia is the most common of the arteriopathies. 1,2 A constellation of symptoms involving the PPS was first described by Frédéric Collet and Jean Sicard in post-traumatic cases as a result of metallic fragments dislodged in the PPS. 3,4 Here, we describe a symptomatic right ICA dissection with PSA treated with the PED system. The use of this stent system From the Section of Vascular and Endovascular Surgery,
