The wall structure of intracranial vessels is different from that in extracranial arteries and this may play a role in their stroke related mechanisms. Dissections often involve a tear between the internal elastic lamina and the media of the vessel wall. Trauma has been associated with intracranial dissections. The most important diagnostic tool in cervicocephalic arterial dissections is clinical suspicion. Dissections are often clinically silent or minimally symptomatic and there is no definite predictor to identify those patients that develop severe clinical sequelae. Choice of treatment depends heavily on the clinical and brain and vascular imaging findings and is made on a patient-by-patient basis. It will also be important to define if patients with intracranial arterial dissections, who have only headache or other benign isolated symptoms, need a specific treatment or are best managed conservatively.