A 52–year–old man with a history of obesity suffered a syncopal event immediately after arising from a seated position. Shortly thereafter, he developed epigastric pain, nausea and vomiting. Initial evaluation revealed orthostatic hypotension, an atraumatic head and neck, epigastric tenderness, leukocytosis, elevated lipase, and mildly elevated LFTs. ECG was normal and troponins were negative. CT of his abdomen revealed gallstones. His initial neurologic exam was normal. He was admitted with a diagnosis of acute gallstone pancreatitis complicated by syncope secondary to orthostatic hypotension. Supportive care was initiated. He developed delirium followed by somnolence thought secondary to narcotic administration. Three nights after admission, he was noted to have a dense paralysis of his right arm. Head CT demonstrated a hypodense lesion consistent with a left–sided MCA territory ischemic CVA. Echocardiogram was normal and telemetry showed no arrhythmias. Subsequent ultrasound and CTA revealed right common carotid dissection. He was treated with aspirin and intravenous heparin and showed slow improvement in his symptoms over the next few weeks.
Carotid artery dissection accounts for approximately 2% of all ischemic strokes. It occurs more commonly as a result of blunt trauma however spontaneous dissection related to connective tissue disorders such as Ehlers–Danlos and Marfan’s also occurs. The reported incidence of carotid artery dissection is increasing likely as a result of increased detection subsequent to more frequent use of MR and CT angiography. The dissection can lead to focal stenosis as hematoma develops within the vessel wall and often thrombosis and embolism as a result of activation of the coagulation cascade. Dissection usually presents with unilateral headache, often with a partial Horner’s syndrome followed by TIA or stroke most commonly in the MCA territory. However, 20% of patients that go on to stroke present with no warning signs. Blunt trauma to the neck is often occult and neurological symptoms can be delayed by hours or days. Early interventions with anticoagulation and endovascular stenting have been shown to improve mortality thus highlighting the importance of early diagnosis. Our patient likely sustained an occult neck injury during his syncopal event that subsequently led to dissection and ischemic stroke 48 hours later.
Carotid artery dissection is becoming an increasingly recognized cause of ischemic stroke, particularly in patients who have sustained blunt trauma. Earlier diagnosis and treatment of dissection leads to better outcomes. As hospitalists have assumed a larger role in the care of patients with trauma and neurologic conditions, we should have an increased awareness of this disease and consider it early in patients suffering from trauma with or without neurologic findings.