Carotid artery dissection is a rare entity, and most cases are attributable to causative factors, which include trauma and local malignancy. The vast majority of dissections present with cerebral infarct; those few that present with local mass effect and respiratory compromise may deteriorate rapidly, requiring urgent resuscitation and consideration of endotracheal intubation, which is often dangerous and/or impossible. The case of a spontaneous internal carotid artery dissection in an otherwise healthy young man, leading to gross mass effect and eventual fatal airway obstruction, is presented here. The need for a high index of suspicion for cervical vascular injury in cases of neck injury (even trivial), known head and neck malignancy/irradiation, or coagulopathy is highlighted. Patients presenting with unilateral neck swelling and symptoms related to mass effect must be assumed to have progressive airway obstruction, and difficult intubation should be anticipated.
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