A patient presentes to the ED with an apparent acute stroke, manifested by hemiparesis.  On further exam, a ptosis and miosis are noted contralateral to the weakness.  What diagnosis is suggested? 

Unilateral headache, focal cerebral ischemic symptoms, and partial Horner syndrome (AKA Raeder's Syndrome - ptosis and miosis without anhydrosis) is the classic presentation of Carotid Artery Dissection













Carotid / Vertebral Artery Dissection

Incidence

• Spontaneous - 3-5 / 100,000
• Traumatic - 1 / 1,000
• Causes up to 10% of CVA in age < 50
• Carotid - average age - 35-50
• Vertebral - average age - 34-44

Pathophysiology

• Right common carotid is branch of brachiocephalic trunk while Left is branch off of aortic arch
• Vertebral - branch off subclavian, goes on to join basilar artery
• Up to 80% of cervical artery (Carotid and Vertebral) dissections caused by trauma (blunt and penetrating) to head or neck
• Can be mild trauma such as exercise or chiropractor
• Intimal tear leads to thrombus / aneurysm / SAH
  
• Fibromuscular dysplasia, Marfan’s syndrome, or osteogenesis imperfecta may predispose

Symptoms (Carotid)

• Triad of headache, ipsilateral oculosympathetic paresis, and contralateral stroke symptoms
• "Oculosympathetic paresis (also referred to as a partial Horner syndrome) is defined as ptosis and miosis without anhidrosis. This phenomenon is caused by ischemia or compression of sympathetic fibers that run from the internal carotid artery plexus. Facial sweating is preserved because the external carotid plexus is not affected. Almost a third of patients have a partial Horner syndrome"
• 75% have headache
• 10% have CN defect
  

Symptoms (Vertebral)

• Unilateral and posterior headache and "lateral medulla ischemia, also known as Wallenberg syndrome, is characterized by dysmetria, ataxia, ipsilateral hemiplegia, and contralateral loss of pain and temperature sensation"
• Signs can be subtle – CN deficits (hoarse voice, pain/numbness, hiccups), posterior circulation deficits (dizzy, N/V)
• May have no neck tenderness
• More likely to affect younger patients that carotid
  

Diagnosis

• Cerebral angiography
• CT-A
• MR-A
• U/S
  

Treatment

• Acute - consider tPA
• Chronic - anti-thrombotics
  

ACEP News. February 2013. Page 17-18.