Clinical Review & Education
Images in Neurology
Ipsilateral Hypoglossal and Oculosympathetic Paresis in Carotid Dissection Slaven Pikija, MD; Peter Unterkreuter, MD
A66-year-oldmanwithoutsignificantmedicalhistorydevelopedspontaneoussudden-onsetleft-sidedheadache.Painstarteddeeplybehind the left ear and quickly spread upward into the head and face on the entire left side up to midline. Pain was controlled with analgesics and pregabalin. Ten days later, he noted that his tongue was swollen and he occasionally bit his tongue on the left side. Clinical examination showed dysarthria, deviation of the tongue to the left, left ptosis, and miosis consistent with hypoglossal palsy and oculosympathetic paresis (Figure, A and B). Magnetic resonance angiography showed carotid dissection in the subcranial segment that compressed the hypoglossal nerve after exit from the hypoglossal canal (Figure, C). The lumen was compromised, suggesting intimal tear. The cause of carotid dissection was not established. He was treated with anticoagulants.
Discussion Cranial nerve palsies in the setting of carotid dissection are present in only 12% of cases. 1 It is already known that highly
placed carotid dissection can produce hemicrania as well as ipsilateral hypoglossal and oculosympathetic paresis; however, combination of the latter two is seldom reported.2,3 Hemicrania is most likely caused by vessel wall expansion. Oculosympathetic paresis is caused by a lesion of the postganglionic sympathetic plexus that surrounds the internal carotid artery. It clinically presents as dysfunction of Müller muscle producing mild ptosis as well as denervation of the iris dilator muscle producing miosis. The function of the hypoglossal nerve is to innervate all tongue muscles. Unilateral dysfunction is evident as tongue deviation toward the paretic side while the genioglossal muscle pushes the tongue toward the affected side. Compression of the hypoglossal nerve is evident in our case as it passes in close proximity to the dissected vessel. The clinical condition gradually improved, and after 3 weeks tongue paresis significantly improved and oculosympathetic paresis subsided.
Figure. Clinical Photographs and T1-Weighted Magnetic Resonance Angiogram B
A
C
Oculosympathetic (A) and hypoglossal (B) paresis was seen on the left side, and T1-weighted magnetic resonance angiography revealed hyperintensity in the thrombosed false lumen of the internal carotid artery (white arrowhead) in the vicinity of the hypoglossal nerve that exits through the hypoglossal canal (black arrowhead) (C).
ARTICLE INFORMATION Author Affiliations: Department of Neurology, Bezirkskrankenhaus Lienz, Lienz, Austria. Corresponding Author: Slaven Pikija, MD, Department of Neurology, Bezirkskrankenhaus Lienz, Emanuel von Hibler-Straße 5, 9900 Lienz, Austria ([email protected]). Accepted for Publication: December 20, 2013.
1050
for the integrity of the data and the accuracy of the data analysis. Study concept and design: Pikija, Unterkreuter. Acquisition, analysis, or interpretation of data: Pikija, Unterkreuter. Drafting of the manuscript: Pikija, Unterkreuter. Critical revision of the manuscript for important intellectual content: Pikija, Unterkreuter. Study supervision: Pikija, Unterkreuter.
Published Online: June 23, 2014. doi:10.1001/jamaneurol.2013.6378.
Conflict of Interest Disclosures: None reported.
Author Contributions: Dr Pikija had full access to all of the data in the study and takes responsibility
REFERENCES
extracranial internal carotid artery. Neurology. 1996;46(2):356-359. 2. Kasravi N, Leung A, Silver I, Burneo JG. Dissection of the internal carotid artery causing Horner syndrome and palsy of cranial nerve XII. CMAJ. 2010;182(9):373-377. 3. Epstein E, Khan MA, Francis D, Sada P, Thuse P. Carotid artery dissection causing hypoglossal nerve palsy [published online June 28, 2012]. BMJ Case Rep. doi:10.1136/bcr.01.2012.5636.
1. Mokri B, Silbert PL, Schievink WI, Piepgras DG. Cranial nerve palsy in spontaneous dissection of the
JAMA Neurology August 2014 Volume 71, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of St. Andrews Library User on 05/16/2015
jamaneurology.com
Images in Neurology
Ipsilateral Hypoglossal and Oculosympathetic Paresis in Carotid Dissection Slaven Pikija, MD; Peter Unterkreuter, MD
A66-year-oldmanwithoutsignificantmedicalhistorydevelopedspontaneoussudden-onsetleft-sidedheadache.Painstarteddeeplybehind the left ear and quickly spread upward into the head and face on the entire left side up to midline. Pain was controlled with analgesics and pregabalin. Ten days later, he noted that his tongue was swollen and he occasionally bit his tongue on the left side. Clinical examination showed dysarthria, deviation of the tongue to the left, left ptosis, and miosis consistent with hypoglossal palsy and oculosympathetic paresis (Figure, A and B). Magnetic resonance angiography showed carotid dissection in the subcranial segment that compressed the hypoglossal nerve after exit from the hypoglossal canal (Figure, C). The lumen was compromised, suggesting intimal tear. The cause of carotid dissection was not established. He was treated with anticoagulants.
Discussion Cranial nerve palsies in the setting of carotid dissection are present in only 12% of cases. 1 It is already known that highly
placed carotid dissection can produce hemicrania as well as ipsilateral hypoglossal and oculosympathetic paresis; however, combination of the latter two is seldom reported.2,3 Hemicrania is most likely caused by vessel wall expansion. Oculosympathetic paresis is caused by a lesion of the postganglionic sympathetic plexus that surrounds the internal carotid artery. It clinically presents as dysfunction of Müller muscle producing mild ptosis as well as denervation of the iris dilator muscle producing miosis. The function of the hypoglossal nerve is to innervate all tongue muscles. Unilateral dysfunction is evident as tongue deviation toward the paretic side while the genioglossal muscle pushes the tongue toward the affected side. Compression of the hypoglossal nerve is evident in our case as it passes in close proximity to the dissected vessel. The clinical condition gradually improved, and after 3 weeks tongue paresis significantly improved and oculosympathetic paresis subsided.
Figure. Clinical Photographs and T1-Weighted Magnetic Resonance Angiogram B
A
C
Oculosympathetic (A) and hypoglossal (B) paresis was seen on the left side, and T1-weighted magnetic resonance angiography revealed hyperintensity in the thrombosed false lumen of the internal carotid artery (white arrowhead) in the vicinity of the hypoglossal nerve that exits through the hypoglossal canal (black arrowhead) (C).
ARTICLE INFORMATION Author Affiliations: Department of Neurology, Bezirkskrankenhaus Lienz, Lienz, Austria. Corresponding Author: Slaven Pikija, MD, Department of Neurology, Bezirkskrankenhaus Lienz, Emanuel von Hibler-Straße 5, 9900 Lienz, Austria ([email protected]). Accepted for Publication: December 20, 2013.
1050
for the integrity of the data and the accuracy of the data analysis. Study concept and design: Pikija, Unterkreuter. Acquisition, analysis, or interpretation of data: Pikija, Unterkreuter. Drafting of the manuscript: Pikija, Unterkreuter. Critical revision of the manuscript for important intellectual content: Pikija, Unterkreuter. Study supervision: Pikija, Unterkreuter.
Published Online: June 23, 2014. doi:10.1001/jamaneurol.2013.6378.
Conflict of Interest Disclosures: None reported.
Author Contributions: Dr Pikija had full access to all of the data in the study and takes responsibility
REFERENCES
extracranial internal carotid artery. Neurology. 1996;46(2):356-359. 2. Kasravi N, Leung A, Silver I, Burneo JG. Dissection of the internal carotid artery causing Horner syndrome and palsy of cranial nerve XII. CMAJ. 2010;182(9):373-377. 3. Epstein E, Khan MA, Francis D, Sada P, Thuse P. Carotid artery dissection causing hypoglossal nerve palsy [published online June 28, 2012]. BMJ Case Rep. doi:10.1136/bcr.01.2012.5636.
1. Mokri B, Silbert PL, Schievink WI, Piepgras DG. Cranial nerve palsy in spontaneous dissection of the
JAMA Neurology August 2014 Volume 71, Number 8
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of St. Andrews Library User on 05/16/2015
jamaneurology.com
