Case Presentation:

A 41–year–old Caucasian male presented to the physician’s office with 1–week history of dysphasia along with transient left posterior jaw pain and chewing difficulty. He also felt that the food clogged on his left inner cheek during every meal. Symptoms were sudden in onset and were progressive. He did not have any trauma to face. On examination he had deviation of his tongue to the left side along with atrophy and fasciculations. There was no Horner’s syndrome. There was no other focal neurological deficit. His blood work including auto–immune as well as vasculitis screen did not show any abnormality. A CT angiogram showed dissection of his internal carotid artery (ICA) just above the bifurcation up to the carotid canal at the base of the skull. An intramural thrombus was noted as well. He was admitted for anticoagulation and a carotid Doppler done as inpatient confirmed the (L) ICA dissection. He was discharged after achieving therapeutic INR and his symptoms had completely resolved at his first follow up appointment.

Discussion:

Even though once considered an uncommon entity, spontaneous internal carotid artery dissection (SICAD) has been increasingly reported with advances in neuro imaging technology. The classic manifesting syndrome would be a triad of hypoglossal nerve palsy, Horner’s syndrome and ischemic stroke. Isolated hypoglossal nerve palsy without Horner’s syndrome is very rare and has many possible etiologies–malignant tumors in the base of the skull, neurinomas, leptomeningeal carcinomatosis, infectious diseases or may even be idiopathic. Carotid or vertebral artery dissection should always be a differential diagnosis. Carotid dissection usually arises from an intimal tear of the artery. The intramural hematoma may grow towards the intima, which cause stenosis of the arterial lumen or towards the adventitia, resulting in aneurismal dilatation that could cause nerve palsy by compressing or stretching the nerve. The best diagnostic method for evaluating the condition is MRI with MR angiography due to its non–invasiveness though the gold standard test would be conventional angiography. We did not require MRA since it was clearly evident with CT angiogram and vascular Doppler ultrasound. Treatment usually involves conservative management with anti–coagulation though rarely endovascular repair may be required for persisting symptoms. In most cases, the prognosis is good.

Conclusions:

Spontaneous internal carotid artery dissection may cause cranial nerve palsy by compression/stretching. Anticoagulation is the mainstay of treatment. Most SICAD heal spontaneously though Surgery/endovascular repair may be needed when symptoms persist/progress.

Figure 1(L) Hypoglossal nerve palsy as evident by deviation of tongue.

Figure 2CT Angiogram shows ICA dissection marked with arrow.