The risk of stroke and management of coiling of the cervical internal carotid artery in the absence of an atherosclerotic carotid bulb lesion is unclear. We report a case of an otherwise healthy 39-year-old woman who developed bilateral sequential strokes associated with bilateral coiled internal carotid arteries. We discuss the risk of stroke and management of coiled carotid arteries as they relate to the patient presented. 1. Introduction Elongation of the internal carotid artery (ICA) can result in tortuosity, coiling, and kinking. The associated stroke risk and management of these vascular anomalies is unclear. We report a case of a 39-year-old female who presented with bilateral sequential strokes associated with 360-degree coil in both cervical ICAs. 2. Case Presentation A 39-year-old female presented to the emergency department with acute onset of right retroorbital and temporal headache associated with left-sided weakness and numbness following sexual intercourse. She was otherwise healthy without cerebrovascular risk factors, tobacco use, or illicit drug use. She was taking oral contraceptives. There was no family history of premature coronary artery disease or stroke. Initial general examination was notable for a blood pressure of 158/98. Neurologic examination revealed a left lower facial droop and hemiparesis. Brain MRI revealed an acute stroke in the right cerebral hemisphere in a watershed distribution (Figure 1(a)). Head MRA demonstrated no flow-related enhancement within the petrous and cavernous segments of the right ICA with reconstitution of the ICA at the ophthalmic artery level. Axial fat-saturated T1-weighted MRI through the skull base demonstrated a distortion of the lumen of the petrous and cavernous segments of the right ICA by a rounded region of increased signal abnormality consistent with a dissection (Figure 1(b)). Conventional 4-vessel cerebral angiography demonstrated 360-degree loops in both cervical ICAs (Figure 1(c)). At the apex of the loop involving the proximal right internal carotid artery, there was a fusiform aneurysm filled with a subintimal thrombus resulting in poor antegrade flow into the distal ICA and cerebral circulation. The 360-degree loop in the mid-cervical portion of the left internal carotid artery was not associated with outflow obstruction. The 360-degree loop in the distal right ICA was not felt to be amenable to surgical intervention by vascular surgery due to the distal nature of the vascular anomaly. She was anticoagulated with warfarin for 7 months followed by treatment with extended-release
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