| John is a 30 year old male who was playing football and was hit in the face by a ball 2 days ago. Today he had an episode of altered speech with some word finding difficulties but nothing else. He has been referred to the TIA clinic. He has some neck pain and a mild headache. |
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On examination you look at his eyes
What do you notice
- He has a mild ptosis (droop) of his left eye
- He has a small "miosed" left pupil
What is this called and what is the significance
This is a left Horner's syndrome which may be caused by a dissection of his left internal carotid artery. The sympathetic supply to the eye travels closely to the internal carotid artery and can be damaged in dissection. The definitive test is an axial MRI scan of the neck.
Axial MRI Neck: Look carefully
Describe what you see
The left ICA intima is full of thrombus (white) with a small central black area of normal arterial lumen. It is possible that he has had some embolism to his left cortex which caused his speech impairment. An MRI DWI will help.
Click to see his MRI DWI brain
What do you see
There is some restricted diffuion in left parietal cortex.
How would you manage this
There do not appear to be any clear advantages of anticoagulation over antiplatelet therapy. I would commence Aspirin and Clopidogrel for at least a month and then a single agent for 6 months while the artery repairs but there is no evidence base. I would consider an angiogram after 3 months to ensure the vessel remains patent and there is no aneurysm formation. There is much variation between clinicians and so follow local guidelines.
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