Case Archives Bilateral Carotid Dissections with Lower Cranial Nerve Dysfunction

This patient presented with hoarseness of voice.  Left vocal cord paresis was noted on endoscopy; neurologic exam was significant for:

Bilateral Horner’s

Palate Deviation to the right

Tongue Deviation to the left

So, based on this involvement of bilateral sympathetic plexi, left vagus, and left hypoglossal nerve was suspected

CTA of the neck showed bilateral distal cervical ICA dissections, with reduced lumen caliber (red) and wall expansion due to intramural hematomas (orange)

Sagittal view of the left side — the larger intramural hematoma on the left goes with left-sided lower cranial nerve issues

Treatment was undertaken with bilateral pipeline devices  — left side done first

Pipeline construct is shown in white arrows

Same for the right side

This one needed some balloon remodeling (no, he did not get worse from it)

The patient made a nice neurologic recovery

Further reading (this article, by Valavanis et al, supports intervention, for those of you who still feel that doing nothing and doing no harm is same thing…)