Background: Carotid arterial dissection is an uncommon but important cause of stroke in pregnancy. Physiological haemodynamic and hormonal changes may increase susceptibility, and management is complex due to competing maternal cerebral perfusion needs and fetal safety.
Aim: To report a case of right internal carotid artery (ICA) dissection with evolving cerebrovascular compromise in pregnancy and describe key principles of haemodynamic and multidisciplinary management.
Case: A 33-year-old G2P2 woman presented at 23 weeks’ gestation with sudden severe headache on a background of IVF conception and prior postpartum pre-eclampsia. CT angiography demonstrated right terminal ICA dissection with a small ischaemic infarct and minimal deficit due to collateral flow. She was managed in ICU with strict blood pressure targets (100–140 mmHg), positional precautions, and dual antithrombotic therapy with aspirin and therapeutic enoxaparin. She subsequently developed recurrent neurological events and hypotensive episodes. MRI showed progression of dissection with new right MCA stenosis despite medical therapy. Antenatal corticosteroids were administered and diagnostic cerebral angiography confirmed stability with no need for intervention. Ongoing management required fludrocortisone for haemodynamic support alongside antiplatelet therapy. She was discharged after a 3-week admission and weaned from haemodynamic support in the third trimester, proceeding to elective caesarean section at 38+1 weeks.
Discussion: This case demonstrates that carotid dissection in pregnancy may evolve despite initial stability. It highlights the need for serial clinical and imaging reassessment and flexible, physiology-driven haemodynamic targets. Early multidisciplinary involvement is essential to balance cerebral perfusion, guide antithrombotic therapy, and support delivery planning in high-risk neurovascular pregnancy.