Dissection of the internal carotid artery is an increasingly recognised cause of acute ischaemic stroke in young adults and children. It may arise spontaneously or secondary to blunt or penetrating trauma. It has been reported after seemingly trivial incidents, such as reversing a car, washing hair, or holding a mobile telephone by flexing the neck against the shoulder. The incidence of carotid dissection is about 2.5–3/100 000/year—similar to aneurysmal subarachnoid haemorrhage.1 The most common presenting features are ipsilateral temporal, retroorbital, or hemicranial pain, Horner’s syndrome, and local cranial nerve palsies, plus potentially devastating cerebral ischaemic events. Although no trial data exist to support the use of anticoagulants, most cerebrovascular specialists advocate initial intravenous heparin then three to six months of warfarin treatment if there have been ischaemic episodes. There is often an interval between onset of symptoms and cerebral infarction enabling the diagnosis to be made and treatment to be instituted.2 Given the potentially fatal or disabling consequences of carotid dissection this window of opportunity is not to be missed. About 80% of ischaemic strokes arise within the first seven days although they can …