A 55-year-old right-handed man is brought to the emergency department after sustaining injuries in a head-on motor vehicle collision. He has a past medical history of migraine headaches, hypertension, and hyperlipidemia. The patient is a chronic smoker, and his medications include aspirin, lisinopril, and atorvastatin. On the way to CT scan, he complains of a severe, sharp headache that radiates to the left side of his neck.
His blood pressure is 135/85 mm Hg and pulse is 102/min and regular. After the head CT is obtained, the patient is unable to speak and develops right-sided weakness. On examination, he is globally aphasic. He has a right homonymous hemianopsia, left pupillary miosis and partial ptosis, and left gaze preference. Neurologic examination shows reduced sensation on the right side of the face and body, right-sided hemiparesis, and an extensor response at the right big toe on plantar cutaneous stimulation.
Which of the following is the most likely diagnosis?

Question

A 55-year-old right-handed man is brought to the emergency department after sustaining injuries in a head-on motor vehicle collision.  He has a past medical history of migraine headaches, hypertension, and hyperlipidemia.  The patient is a chronic smoker, and his medications include aspirin, lisinopril, and atorvastatin.  On the way to CT scan, he complains of a severe, sharp headache that radiates to the left side of his neck.
His blood pressure is 135/85 mm Hg and pulse is 102/min and regular.  After the head CT is obtained, the patient is unable to speak and develops right-sided weakness.  On examination, he is globally aphasic.  He has a right homonymous hemianopsia, left pupillary miosis and partial ptosis, and left gaze preference.  Neurologic examination shows reduced sensation on the right side of the face and body, right-sided hemiparesis, and an extensor response at the right big toe on plantar cutaneous stimulation.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_9668_0692_853d_7fa08d3aff11_MD0002_00 This patient's presentation suggests acute traumatic left internal carotid artery (ICA) dissection causing ipsilateral middle cerebral artery (MCA) stroke and ipsilateral Horner syndrome. Vascular dissections commonly cause acute stroke in patients age < 55 and are categorized as traumatic or spontaneous (Table). ICA dissection leads to blood entering between the inner and outer arterial layers, which can form blood clots and also lead to embolic stroke. Non-ischemic ICA dissection typically presents with a thunderclap headache (reaching maximal intensity in < 1 minute) that radiates to the neck. Ischemic dissections may present with transient vision loss, ischemic stroke, or embolic stroke. Because post-ganglionic sympathetic fibers run on the outer surface of the ICA to supply the head, ICA dissection may damage these fibers and lead to partial ipsilateral Horner syndrome (partial ptosis and miosis without anhidrosis). Neck imaging (MRA/CTA is preferred) may show the ICA with a tapered, flame-shaped appearance rather than the blunted-stump appearance of vascular occlusions (Figure). Prompt recognition and treatment (eg, anticoagulation, antiplatelet therapy, and endovascular or surgical endovascular repair) can decrease the risk of stroke, neurologic disability, and death. Neck imaging (Choice B) Cerebral venous sinus thrombosis can present with thunderclap or gradual headache associated with focal neurologic deficits. However, it usually does not present with Horner syndrome. (Choice C) Complex migraine is considered a diagnosis of exclusion and can present with throbbing headache associated with nausea, vomiting, photophobia, and focal neurologic deficits. However, the headache is rarely described as a thunderclap and is not associated with Horner syndrome. (Choice D) Subarachnoid hemorrhage can present with a thunderclap headache and meningeal signs but usually does not present with Horner syndrome. (Choice E) Vertebral dissection can present with thunderclap headache, Horner syndrome due to infarction of the ipsilateral dorsolateral medulla (Wallenberg syndrome), loss of sensation on the face and contralateral body, nystagmus, ataxia, and dysarthria. However, aphasia and weakness are not typically seen in this condition. Educational objective: ICA dissection typically occurs after head or neck trauma with acute neurologic deficits, headache that may radiate to the neck, and possible Horner syndrome. MRA/CTA of the neck is preferred to diagnose vascular dissection (ICA or vertebral), which typically has a flame-shaped, tapered appearance. Prompt recognition and treatment can decrease the risk of stroke, neurologic disability, and death. __________ References: Cervical carotid artery dissection: current review of diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/22301716)

A 55-Year-Old Right-Handed Man Is Brought to the Emergency Department