Upper cranial nerve palsy resulting from spontaneous carotid dissection.
BACKGROUND
Upper cranial nerve palsy has a variety of causes such as cerebral and nerve ischemia, diabetes, infectious and non-infectious meningitis, subarachnoid hemorrhage and intracranial aneurysm. CASE 1 : A 45-year-old man suffered from holocephalic headaches and a right-sided neck pain for two weeks. He presented to our emergency department because of a sudden ptosis of the right eye. On admission neurological examination revealed a right sided Horner's syndrome and hypesthesia of the right side of the face. Magnetic resonance angiography identified a circumscribed dissection of the right extracranial internal carotid artery originating from the carotid bifurcation. Conventional angiography 2 weeks later showed a nearly recanalized artery. CASE 2 : A 55-year-old previously healthy man without cardiovascular risk factors developed right sided neck pain when loading a seeder with several sacks of crop. A few hours later he noticed a left-sided weakness. On admission a severe left sided hemiparesis and a mild neglect were present. Duplex sonography revealed a right-sided distal internal carotid artery (ICA) occlusion. The next morning the patient complained of double vision; he had a right-sided pupil-sparing oculomotor palsy. The diagnosis of ICA dissection was confirmed by conventional angiography, at that time showing a partially recanalized ICA without involvement of the cavernous region by the dissection.


CONCLUSIONS
ICA dissection must be included in the differential diagnosis of upper cranial nerve palsy and should be assessed by duplex ultrasound and magnetic resonance imaging. A possible explanation is nerve ischemia due to a transient or permanent interruption of the blood supply by compression of the vasa nervorum originating from the intracranial carotid artery.
Wessels
T
T
Dept. of Neurology, Justus-Liebig-Universität Giessen, Am Steg 14, 35385 Giessen, Germany. tiemo.wessels@neuro.med.uni-giessen.de
Röttger
C
C
Kaps
M
M
Traupe
H
H
Stolz
E
E
D020215:Carotid Artery, Internal, Dissection / Q000150:complications* / Q000473:pathology; D003389:Cranial Nerve Diseases / Q000209:etiology* / Q000473:pathology; D006801:Humans; D018810:Magnetic Resonance Angiography / Q000379:methods; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination
Cerebrovasc Dis. 2002;14(3-4):264-5
12403963
Ann Neurol. 1989 Mar;25(3):286-90
2729917
Neurology. 2001 Sep 11;57(5):827-32
11552012
Stroke. 1998 Dec;29(12):2653-5
9836781
J Neurol. 1995 Mar;242(4):231-8
7798122
Ann Neurol. 1997 Feb;41(2):273-6
9029079
J Neurol Sci. 2001 Mar 1;184(2):203-7
11239957
Neurology. 1971 Jun;21(6):609-14
4327154
Neurology. 1980 Feb;30(2):210-1
6243763
Can J Neurol Sci. 2001 Aug;28(3):265-9
11513348
J Neurol Neurosurg Psychiatry. 1993 Nov;56(11):1191-9
8229030
Neurology. 1996 Feb;46(2):356-9
8614494
Br J Ophthalmol. 1996 Feb;80(2):177-81
8814752
Eur Neurol. 1997;37(1):3-12
9018025
J Neurol. 2001 Oct;248(10):909-10
11697533