At the Mayo Clinic in Rochester, Minn., Brittany Strelow is an instructor in internal medicine and Nathan P. Young is an assistant professor of neurology. The authors have disclosed no potential conflicts of interest, financial or otherwise.
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CASEA 48-year-old man presented to a primary care clinic with persistent headache and concern for recurrent sinusitis.HistoryHis past medical history included anxiety disorder, narcolepsy, labile hypertension, and migraine headaches. His medications included hydrochlorothiazide and methylphenidate. One month ago, he developed fever, sore throat, chills, and persistent severe cough and presented to an urgent care clinic, where he was treated symptomatically with fluticasone nasal, acetaminophen, ibuprofen, and albuterol. His fever and cough improved.Twelve days ago, he presented to the ED with sinus congestion, rhinorrhea, and bilateral maxillary sinus pressure. He was treated with amoxicillin and oxymetazoline nasal spray. Bifacial and sinus pressure with rhinorrhea persisted and became associated with a new right hemicranial pain that he had not experienced before. Without trigger or warning, he developed severe stabbing pain behind his right eye radiating toward the back of his neck, which he rated as a 10 on a 0-to-10 pain intensity rating scale. The intense pain lasted about 1 minute and subsided with residual moderate pain and occasionally complete resolution.The severe pain occurred 6 to 10 times per day. He noted tearing of his eye and congestion in the right side of his nose without redness or discoloration of his face. He reported mild photophobia and nausea without vomiting. Over-the-counter anti-inflammatory medications, analgesics, and decongestants did not significantly relieve symptoms. He had no history of trauma to the head and neck or neurologic symptoms such as change in vision, language, sensation, or motor function. He reported migraine headaches occurring years before that were distinctly different in character and location than the current pain.Physical examinationThe patient's vital signs were: BP, 151/102 mm Hg; heart rate, 64; and oral temperature, 36.6° C (97.9° F). He generally appeared well. His tympanic membranes were clear with no erythema. The right nasal turbinates were extremely edematous, erythematous, and nearly occluded the nasal passage. The left nare was slightly erythematous and edematous. He had tenderness to palpation, especially over the frontal sinus and slightly over the right maxillary sinus. His pharynx was without erythema or exudate.Ocular examination revealed anisocoria with a smaller right pupil and mild right ptosis. The anisocoria was greater in dim light than bright light, consistent with Horner syndrome (Figure 1). Cranial nerves were otherwise normal as well as funduscopic examination, strength, coordination, gait, sensation, and reflexes. He had no cervical lymphadenopathy or carotid bruit.Because of the new unilateral headache in association with ipsilateral Horner syndrome, a brain MRI and magnetic resonance angiogram (MRA) of the neck were recommended. The brain MRI revealed increased T2 signal in the wall of the carotid artery consistent with a dissection (Figure 2). The MRA was not performed because of extensive artifact due to the patient's dental braces; instead, a CT angiogram of the neck confirmed a carotid dissection at the skull base (Figure 3). In addition, the CT angiogram showed evidence of a dysplastic widening of the left internal carotid artery, likely due to previous dissection or fibromuscular dysplasia.DISCUSSIONCarotid artery dissection is the most common cause of ischemic stroke in young adults, accounting for 8% to 25% of strokes in patients under age 45 years.1-4 Carotid artery dissection is most common in women ages 42 to 52 years who have no or minimal arthrosclerotic factors.