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Images in Neurology |

Oculosympathetic Paratrigeminal Paralysis With Isolated V2 Involvement in Carotid Artery Dissection

Yaroslav Epifanov, MD; Tobias Back, MD
Arch Neurol. 2007;64(3):448-449. doi:10.1001/archneur.64.3.448.
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A 57-year-old man developed sudden left-sided hemicranial pain 4 days prior to admission. He was taking no medication and his medical history was unremarkable. On the day after admission, the pain involved the infraorbital region, which became numb. Left ptosis and miosis were noted. Clinical examination showed sensory loss in the second trigeminal branch (V2) accompanied by ipsilateral oculosympathetic paralysis (Horner syndrome). Measurement of somatosensory evoked potentials registered slowed conduction in the left V2 branch. Magnetic resonance imaging showed the dissection of the left internal carotid artery at the skull base with a characteristic hyperintense wall hematoma seen on T1-weighted images (Figure 1A). Magnetic resonance angiography 5 days after symptom onset showed typical tapering of the internal carotid artery with high-grade stenosis of the petrous segment (Figure 1B), which was confirmed by the biphasic Doppler spectrum (“stump signal”) of the proximal internal carotid artery (Figure 2A). Diffusion-weighted magnetic resonance images did not show any ischemic lesions. Oral anticoagulation therapy with warfarin sodium was initiated. On discharge, the patient was free of pain but still showed the clinical signs mentioned. At a 3-month follow-up visit, the sensory disturbance had resolved, whereas residual incomplete Horner syndrome persisted. The successful recanalization of the left internal carotid artery was documented by magnetic resonance angiography (not shown) and normalized Doppler spectra (Figure 2B). Prophylaxis with warfarin was changed to aspirin.

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Figure 1.

Coronal magnetic resonance (MR) imaging. A, A fat-suppressed T1-weighted MR image shows a hyperintense wall hematoma in the left petrous internal carotid artery segment (arrows). B, The tapering appearance (arrowheads) seen on coronal MR angiography is typical of an arterial dissection. L indicates left; R, right.

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Figure 2.

Color-coded Doppler sonography of the proximal left internal carotid artery (ICA). A, A pathologic biphasic Doppler spectrum lacking diastolic flow (“stump signal”) 5 days after symptom onset indicates distal ICA obstruction or occlusion. B, The Doppler spectrum obtained at a follow-up examination 3 months later shows a normalized spectrum, indicating successful recanalization.

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