History: A 40 year-old man presents with right neck pain that started while he was wrestling with his friend 2 days ago. Today he also has a right-sided frontotemporal headache and complains that he can hear his heartbeat ringing in his right ear. Vital signs are normal. There is no evidence of head or neck trauma. Neurologic exam shows the abnormalities of the right eye seen. What is the most likely diagnosis?
- Carotid artery dissection
- Right third cranial nerve palsy
- Severe neck strain
- Temporal arteritis
- Vertebral artery dissection
Answer: 1. Carotid artery dissection is uncommon but is a significant
cause of stroke in the young. It usually occurs after major or minor neck trauma. The most common symptom is headache, which is usually frontotemporal, followed by neck pain; pulsatile tinnitus occurs occasionally. Neurologic abnormalities, classically a partial ipsilateral Horner syndrome (no anhydrosis), often occur days after the onset of pain and can be quite subtle. In this case the patient’s right eye miosis is obvious, but the ptosis is very mild.
Neck strain would be a diagnosis of exclusion and is less likely here given the classic presentation of carotid dissection.
Third cranial nerve palsy produces severe ptosis, pupillary dilation, and ophthalmoplegia.
Temporal arteritis occurs almost exclusively in those older than 50 years and is not associated with trauma.
Vertebral artery dissection also occurs after neck trauma but usually causes occipital and nuchal pain and brainstem deficits such as vertigo and ataxia.