{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T00:53:34Z","timestamp":1782867214125,"version":"3.54.5"},"reference-count":32,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"26","license":[{"start":{"date-parts":[[2026,6,29]],"date-time":"2026-06-29T00:00:00Z","timestamp":1782691200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2026,6,29]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>Although intraluminal shunt insertion during carotid endarterectomy (CEA) is widely used to maintain cerebral perfusion, distal intimal injury of the internal carotid artery (ICA) can occur as a rare yet consequential complication.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>An 82-year-old man with an elongated styloid process who underwent CEA for left ICA stenosis at the C2 vertebral level developed a new progressive high-grade stenosis immediately distal to the endarterectomy site, likely associated with shunt manipulation. Preoperative images demonstrated that the distal ICA segment at the C1 vertebral level was positioned between the styloid process anterolaterally and the transverse process of C1 posteromedially, in closer proximity to these osseous structures than on the right side. The dissected segment corresponded to the region of closest proximity between the ICA and the transverse process of C1. The patient underwent carotid artery stent placement for the distal dissected stenosis without neurological sequelae.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>This case suggests that an Eagle syndrome\u2013like osseous-vascular configuration may predispose the artery to shunt-related injury during CEA. Meticulous preoperative assessment of the relationship between the ICA and both the transverse process of C1 and the styloid process may help mitigate the risk of distal ICA dissection in high cervical lesions with an elongated styloid process.<\/jats:p>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/thejns.org\/doi\/10.3171\/CASE26320\">https:\/\/thejns.org\/doi\/10.3171\/CASE26320<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case26320","type":"journal-article","created":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T00:10:24Z","timestamp":1782864624000},"source":"Crossref","is-referenced-by-count":0,"title":["Distal internal carotid artery dissection after carotid endarterectomy for a high cervical lesion suggesting an Eagle-like mechanism of shunt-related injury: illustrative case"],"prefix":"10.3171","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4940-456X","authenticated-orcid":true,"given":"Koki","family":"Ito","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eriko","family":"Kamijo","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kazuki","family":"Kushi","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tatsuki","family":"Mochizuki","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Taku","family":"Nonaka","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bikei","family":"Ryu","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo"},{"name":"Department of Neuroendovascular Therapy, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shinsuke","family":"Sato","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo"},{"name":"Department of Neuroendovascular Therapy, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tatsuya","family":"Inoue","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo"},{"name":"Department of Neuroendovascular Therapy, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yukiko","family":"Tsutsumi","sequence":"additional","affiliation":[{"name":"Department of Neuroendovascular Therapy, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yasunari","family":"Niimi","sequence":"additional","affiliation":[{"name":"Department of Neuroendovascular Therapy, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Akitsugu","family":"Kawashima","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, St. Luke\u2019s International Hospital, Chuo-ku, Tokyo"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"7","key":"bib1","series-title":"N Engl J Med","first-page":"445","article-title":"Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis","volume":"325","author":"North American Symptomatic Carotid Endarterectomy Trial Collaborators","year":"1991","unstructured":"North American Symptomatic Carotid Endarterectomy Trial CollaboratorsBarnett HJMTaylor DWBeneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991;325(7):445-453. doi:10.1056\/NEJM199108153250701"},{"key":"bib2","series-title":"Surg Neurol Int","first-page":"101","article-title":"Elongated styloid process as a possible cause of distal carotid artery dissection after carotid endarterectomy using indwelling shunt: a case report","volume":"13","author":"Suzuki","year":"2022","unstructured":"Suzuki TKimura THasegawa HElongated styloid process as a possible cause of distal carotid artery dissection after carotid endarterectomy using indwelling shunt: a case report. Surg Neurol Int. 2022;13:101. doi:10.25259\/SNI_185_2022"},{"issue":"6","key":"bib3","series-title":"Br J Neurosurg","first-page":"862","article-title":"Distal internal carotid artery dissection due to the carotid shunt during carotid endarterectomy","volume":"29","author":"Katsuno","year":"2015","unstructured":"Katsuno MTanikawa RHashimoto MMatsuno A.Distal internal carotid artery dissection due to the carotid shunt during carotid endarterectomy. Br J Neurosurg. 2015;29(6):862-864. doi:10.3109\/02688697.2015.1054357"},{"key":"bib4","series-title":"Int J Vasc Med","first-page":"816937","article-title":"Distal cervical carotid artery dissection after carotid endarterectomy: a complication of indwelling shunt","volume":"2010","author":"Tamaki","year":"2010","unstructured":"Tamaki TYoji NSaito N.Distal cervical carotid artery dissection after carotid endarterectomy: a complication of indwelling shunt. Int J Vasc Med. 2010;2010:816937. doi:10.1155\/2010\/816937"},{"issue":"3","key":"bib5","series-title":"Neurosurgery","first-page":"441","article-title":"Distal cervical carotid dissection after carotid endarterectomy: a complication of indwelling shunt?","volume":"19","author":"Loftus","year":"1986","unstructured":"Loftus CMDyste GNReinarz SJHingtgen WL.Distal cervical carotid dissection after carotid endarterectomy: a complication of indwelling shunt? Neurosurgery. 1986;19(3):441-445. doi:10.1227\/00006123-198609000-00018"},{"issue":"5","key":"bib6","series-title":"Arch Otolaryngol Head Neck Surg","first-page":"584","article-title":"Elongated styloid processes: report of two cases","volume":"25","author":"Eagle","year":"1937","unstructured":"Eagle WW.Elongated styloid processes: report of two cases. Arch Otolaryngol Head Neck Surg. 1937;25(5):584-587. doi:10.1001\/archotol.1937.00650010656008"},{"issue":"2","key":"bib7","series-title":"AMA Arch Otolaryngol","first-page":"172","article-title":"Elongated styloid process: symptoms and treatment","volume":"67","author":"Eagle","year":"1958","unstructured":"Eagle WW.Elongated styloid process: symptoms and treatment. AMA Arch Otolaryngol. 1958;67(2):172-176. doi:10.1001\/archotol.1958.00730010178007"},{"issue":"1","key":"bib8","series-title":"BMC Neurol","first-page":"333","article-title":"The eagle jugular syndrome","volume":"19","author":"Zamboni","year":"2019","unstructured":"Zamboni PScerrati AMenegatti EThe eagle jugular syndrome. BMC Neurol. 2019;19(1):333. doi:10.1186\/s12883-019-1572-3"},{"issue":"5","key":"bib9","series-title":"Clin Anat","first-page":"545","article-title":"Eagle\u2019s syndrome: a review of the literature","volume":"22","author":"Piagkou","year":"2009","unstructured":"Piagkou MAnagnostopoulou SKouladouros KPiagkos G.Eagle\u2019s syndrome: a review of the literature. 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Oper Neurosurg. 2019;17(6):554-561. doi:10.1093\/ons\/opz012"},{"issue":"2","key":"bib15","series-title":"Neuroradiol J","first-page":"251","article-title":"Eagle jugular syndrome presenting with intracranial hypertension\u2014diagnosis and illustration of pathophysiology by multi-modality imaging","volume":"37","author":"Leung","year":"2024","unstructured":"Leung HSChoi CHJLau EHLWong WYECheung CYChan YYA.Eagle jugular syndrome presenting with intracranial hypertension\u2014diagnosis and illustration of pathophysiology by multi-modality imaging. Neuroradiol J. 2024;37(2):251-256. doi:10.1177\/19714009231187347"},{"issue":"1","key":"bib16","series-title":"J Neurosurg","first-page":"90","article-title":"Eagle syndrome as a cause of transient ischemic attacks","volume":"110","author":"Farhat","year":"2009","unstructured":"Farhat HIElhammady MSZiayee HAziz-Sultan MAHeros RC.Eagle syndrome as a cause of transient ischemic attacks. 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