A 28-year-old woman comes to the emergency department due to left-sided headache and neck pain after a fall while skiing the day prior. She took ibuprofen and rested but the symptoms persisted, and today, she also had transient leg weakness. The patient has no prior medical conditions. She occasionally drinks alcohol but does not use tobacco or illicit drugs. Family history is significant for stroke in her father. Temperature is 37.2 C (99 F), blood pressure is 134/86 mm Hg, and pulse is 90/min. Physical examination shows mild ptosis and miosis of the left eye. There is no excessive lacrimation or rhinorrhea. Funduscopic examination is normal. No carotid bruit is present. Heart and lung sounds are normal. Neurological examination shows normal motor strength, deep tendon reflexes, and sensation in bilateral upper and lower extremities. Which of the following is the most likely cause of this patient's current condition?

Question

A 28-year-old woman comes to the emergency department due to left-sided headache and neck pain after a fall while skiing the day prior.  She took ibuprofen and rested but the symptoms persisted, and today, she also had transient leg weakness.  The patient has no prior medical conditions.  She occasionally drinks alcohol but does not use tobacco or illicit drugs.  Family history is significant for stroke in her father.  Temperature is 37.2 C (99 F), blood pressure is 134/86 mm Hg, and pulse is 90/min.  Physical examination shows mild ptosis and miosis of the left eye.  There is no excessive lacrimation or rhinorrhea.  Funduscopic examination is normal.  No carotid bruit is present.  Heart and lung sounds are normal.  Neurological examination shows normal motor strength, deep tendon reflexes, and sensation in bilateral upper and lower extremities.  Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d59c_74e9_bc81_f3a507c3aad5_MD0003_00 This young patient has unilateral headache, neck pain, and partial Horner syndrome following a fall and likely also had a transient ischemic attack (TIA) (ie, transient leg weakness). This presentation suggests internal carotid artery dissection, a common cause of stroke in young patients. Internal carotid dissection may occur spontaneously or after infections or minor trauma (eg, sports injuries, falls). Patients with certain connective tissue diseases (eg, Ehlers-Danlos) and those who smoke, have uncontrolled hypertension, or use oral contraceptives are at increased risk. Injury to the arterial intima allows blood to flow into the vessel wall, leading to the formation of a false lumen, aneurysm, or most commonly, an intramural hematoma. This can lead to arterial obstruction or thromboembolic events; cerebral ischemia (eg, stroke, TIA) is a common complication. Distension of the sympathetic fibers that travel along the internal carotid artery lead to partial Horner syndrome characterized by ptosis and miosis (anhidrosis, the third characteristic component of Horner syndrome, does not occur with partial Horner syndrome as the sympathetic fibers responsible for facial diaphoresis travel along the external carotid artery). Other clinical features (not always seen) include tinnitus and carotid bruit. The diagnosis of internal carotid artery dissection is confirmed with CT or MR angiography. Management of stroke due to dissection is similar to other ischemic strokes and includes thrombolysis in appropriate patients, and mechanical thrombectomy for large vessel (eg, middle cerebral artery) occlusions. Although there is a risk of extension of the hematoma, thrombolysis is generally considered to have similar risks as non-dissection-related ischemic strokes. Further management for both ischemic stroke and TIA includes antithrombotic therapy (eg, aspirin, anticoagulation). appropriate patients (Choice B) Cluster headaches can cause ptosis, miosis, and unilateral headaches, but the headaches are characterized by recurrent attacks of severe stabbing pain that occurs near the orbit. Additionally, they are typically associated with tearing, conjunctival injection, and rhinorrhea, not weakness. (Choice C) Diffuse axonal injury occurs after major trauma and typically causes obtundation and coma. Horner syndrome is unexpected. (Choice D) An unruptured intracranial aneurysm is typically asymptomatic but can cause headache, third nerve palsy, facial pain, and pupillary dilation (as opposed to pupillary constriction); weakness and neck pain is unexpected. Ruptured aneurysms result in subarachnoid hemorrhages, characterized by thunderclap headaches and nuchal rigidity. (Choice E) Migraine with brainstem aura typically presents with vertigo, dysarthria, ataxia, and visual disturbances followed by a severe, throbbing occipital headache. Educational objective: Internal carotid artery dissection is a common cause of stroke in young patients and can occur spontaneously or after mild trauma or illness. It is typically characterized by partial Horner syndrome (ptosis and miosis without anhidrosis), unilateral headache and neck pain, and cerebral ischemia (transient ischemic attack, stroke).

A 28-Year-Old Woman Comes to the Emergency Department Due to Left-Sided