A 36-year-old man reported 4 weeks of left-sided headache and neck pain, with left miosis and ptosis. This had started during vigorous exercise, including abrupt cervical movements, and had been constant since. Six years before he had developed three episodes of numbness in the right arm and leg, each lasting around 15 min, thought to anxiety related. He had no cardiovascular risk factors or history of toxic intake. He had been treated for epilepsy from age 23, but had been seizure free for 11 years.
On examination, there was a left-sided Horner’s syndrome, comprising miosis and mild ptosis, but no other abnormalities. Laboratory testing and ECG were unremarkable.
MR scan of brain showed the parenchyma was normal, but MR cerebral angiogram showed the left cervical internal carotid artery had a narrowed eccentric lumen, with surrounding crescent-shaped mural thrombus, consistent with arterial dissection (figure 1). CT cervical angiogram identified bilateral extracranial…