Horner's syndrome and headache due to carotid artery disease

A patient with internal carotid artery dissection

BACKGROUND AND PURPOSE

The purpose of this case report is to raise physical therapist awareness of Horner syndrome as a "red flag" for immediate medical referral.

CASE DESCRIPTION

A 45-year-old man sought physical therapy for examination and treatment of neck pain and headache symptoms 5 days after experiencing a whiplash-type injury while waterskiing. His complaints were similar to a prior condition diagnosed as occipital neuralgia that had successfully responded to education, cervical and thoracic joint mobilization, and exercise provided by a physical therapist. The initial examination findings also were similar to those of the previous episode. However, signs consistent with Horner syndrome were noted on the second visit. This finding raised immediate concern on the part of the treating clinician and resulted in prompt physician referral, medical diagnosis, and intervention.

OUTCOMES

A magnetic resonance imaging angiogram revealed an internal carotid artery dissection. A successful outcome was achieved over the course of 6 months through medical intervention, which consisted of anticoagulant therapy and modification of activity levels.

DISCUSSION

In this case, the patient's sudden onset of signs of Horner syndrome was indicative of a medical emergency-internal carotid artery dissection.

Disorders of the pupil

Pupil size is determined by the interaction of the parasympathetic and the sympathetic nervous system. The parasympathetic system conducts the light reaction with its major center in the dorsal midbrain. The sympathetic nervous system acts either directly on the dilator muscle (peripherally) or centrally by inhibiting the Edinger-Westphal nucleus. Psychosensory reactions are transmitted via the sympathetic system. The afferent input of the light reflex system in humans is characteristically wired, allowing a detailed analysis of a lesion of the afferent input. Even in humans a subgroup of ganglion cells containing melansopsin plays an important role as a light sensor for the pupillary system. To diagnose normal pupillary function, pupils need to be isocoric and react bilaterally equally to light. Anisocoria indicates a problem of the efferent pupillary pathway. Pupillary disorders may involve the afferent pathways (relative afferent pupillary defect) or the efferent pathways. Physiological anisocoria is a harmless condition that has to be distinguished from Horner's syndrome. In this case pharmacological testing with cocaine eye-drops is helpful. Disorders of the parasympathetic system will impair the light response. They include dorsal midbrain syndrome, third-nerve palsy, and tonic pupil. Tonic pupils are mainly idiopathic and do not need imaging. Disorders of the iris, including application of cholinergic agents, need also to be considered in impaired pupillary light reaction.

Carotid dissection: a common cause of Horner's syndrome

PURPOSE

To highlight that internal carotid artery dissection is a common cause of Horner's syndrome and that it is important to diagnose dissection as anticoagulation can prevent carotid thrombosis and embolism.

METHODS

Five case reports are presented of patients with Horner's syndrome secondary to carotid dissection. One patient had carotid dissection secondary to trauma, two had spontaneous dissections and two had dissections in the settings of other illness. A literature search was performed on carotid dissection as a cause of Horner's syndrome and its diagnosis and management.

RESULTS

The case reports and literature highlight that dissection is under-recognized as a cause of Horner's syndrome and can be missed. The investigation of choice is a magnetic resonance imaging and angiography scan of the head and neck. The treatment advocated is anticoagulation for 3-6 months.

CONCLUSION

Carotid dissection should be suspected in patients with Horner's syndrome, particularly if head or neck pain is present.

Ophthalmologic manifestations of internal carotid artery dissection

PURPOSE

To report the ophthalmologic symptoms and signs associated with extracranial internal carotid artery dissection.

METHODS

One hundred forty-six consecutive patients with extracranial internal carotid artery dissection were evaluted; 29 were studied retrospectively from 1972 to 1984 and 117 prospectively from 1985 to 1997.

RESULTS

Sixty-two percent of patients (91/146) with extracranial internal carotid artery dissection had ophthalmologic symptoms or signs that were the presenting symptoms or signs of dissection in 52% (76/146). Forty-four percent (65/146) had painful Horner syndrome, which remained isolated in half the cases (32/65). Twenty-eight percent (41/146) had transient monocular visual loss, which was painful in 31 cases, associated with Horner syndrome in 13 cases, and described as "scintillations" or "flashing lights"-often related to postural changes or exposure to bright lights-suggesting acute choroidal hypoperfusion in 23 cases. Four patients had ischemic optic neuropathy; one had diplopia. Among the 76 patients with ophthalmologic symptoms or signs as the presenting features of carotid dissection, a nonreversible ocular or hemispheric stroke later occurred in 27, within a mean of 6.2 days (range, 1 hour to 31 days). Eighteen patients had a stroke within the first week after the onset of neuro-ophthalmic symptoms and signs, and 24 had a stroke within the first 2 weeks.

CONCLUSION

Ophthalmologic symptoms or signs are frequently associated with and are often the presenting features in internal carotid artery dissection. Painful Horner syndrome or transient monocular visual loss should prompt investigations to diagnose carotid artery dissection and begin early treatment to prevent a devastating ocular or hemispheric stroke.

Oculosympathetic alterations in migraine patients

Oculosympathetic function was studied in 20 headache-free migraine patients and in 20 controls. Pupillary investigation was performed under basal conditions, and after instillation of tyramine (2%) and phenylephrine (1%) eyedrops. Each test was performed twice shortly after a spontaneous attack and then repeated after 7 and 15 days. In the patients, the normal mydriatic response induced by tyramine was significantly (p<0.001) reduced and phenylephrine instillation caused a significant (p<0.01) pupillary dilatation in both the assessments performed shortly after the attack. These abnormal responses were bilateral in all patients and slightly anisocoric in some. They were significantly (p<0.001) more pronounced in the patients who had pain and pronounced vascular features. The reduced oculosympathetic response to tyramine, as well as the hypersensitivity to phenylephrine, was less evident 7 days after the attack and absent after 15 days. A transient and bilateral post-ganglionic oculosympathetic hypofunction, with adrenoceptor hypersensitivity, was found to be temporally related to the migraine attack, regardless of the side or predominant side of pain.

Internal carotid artery dissection: an animal model?

This paper describes an internal carotid artery (ICA) dissection model in a rabbit. An animal model for ICA dissection has not been described. New Zealand White rabbits were anaesthetized and surgical microdissection performed to expose the right internal carotid artery. A small arteriotomy was performed and a subadventitial plane of dissection created using blunt dissection and injected heparinized saline. The adventitia was sutured and the animals were recovered after closure of the wound. The procedure was repeated on the left ICA after 7 days with removal of the left ICA for control samples and removal of the right ICA to obtain sample specimens. The brain was also removed. A total of 11 control specimens and 9 sample specimens were obtained. The mean length of these specimens (n = 20) was 5.5 mm (range 5-6 mm). The mean length of dissection of the control specimens (n = 11) was 2.2 mm (range 2-3 mm). The mean length of dissection on sample specimens (n = 9) was 2 mm (range 1-3 mm). There was no extension of the arterial dissection. There was no intraluminal thrombosis or cerebral infarction. This model was able to induce arterial wall dissection in a rabbit. There was no extension of the induced dissection over 7 days. No local arterial or cerebral ischemic complications developed from the dissection.

Aortic dissection decades following internal carotid artery dissection--report of two cases

Recurrent dissections involving carotid, vertebral, or renal arteries have been described in patients with spontaneous cervical artery dissections, with a maximal interval between dissections of fourteen years. The authors describe 2 patients in whom aortic dissections developed twenty-five and forty years, respectively, following carotid artery dissections. These 2 patients constituted 8% of the total number of patients from Rochester, Minnesota, who were diagnosed with aortic dissection between 1987 and 1992. The first patient, a forty-five-year-old woman, presented in 1948 with right neck pain and headache, associated with several episodes of transient numbness of the right face and numbness and clumsiness of the left upper and lower extremities. Examination showed right miosis. Angiography showed a stenosis of the extracranial right internal carotid artery beginning several centimeters from the bifurcation. She died at age eighty-five from an aortic dissection. The second patient, a thirty-eight-year-old man, noted left orbital and frontotemporal headaches and drooping of the left eyelid in 1962. Examination showed left oculosympathetic palsy. Angiography showed stenosis and an aneurysm in the midportion of the extracranial left internal carotid artery. He died at age sixty-three from an aortic dissection. These cases suggest that following a carotid artery dissection the risk of a recurrent arterial dissection may remain elevated for a prolonged period of time and the recurrent dissection may involve the aorta.

Recurrent neck pain as a variant of migraine: description of four cases

Four patients who had recurrent attacks of idiopathic unilateral neck pain and tenderness of the ipsilateral carotid artery are described. Two patients had never had headache. The other two had migraine without aura. All patients had dilatation of extracranial arteries during the attacks (telethermographic examination), oculosympathetic hypofunction (pupillary tests), and positive responses to vasoactive drugs which are commonly used for migraine treatment. Recurrent neck pain involving the carotid artery seems to be a variant form of migraine that may occur alone or in association with headache in patients with involvement of extracranial arteries.

Spontaneous internal carotid artery dissection: early diagnosis and management in 44 patients

First symptoms and initial clinical, ultrasonographic and neuroradiological findings ascertained a mean of 5.6 days (SD = 5.6 days), 7.7 days (7.0), and 11.2 days (8.0) after symptom onset were analysed in 44 patients who suffered a spontaneous internal carotid artery dissection (ICD) verified by magnetic resonance imaging, angiography, or both. Common symptoms signalling dissection were unilateral headache in 68%, transient ischaemic attack in 20%, and cerebral infarction in 9%. Severe pain preceded cerebral ischaemia by more than 3 days in 60% of those patients who eventually suffered a stroke. However, only 2 were admitted because of pain alone and 33 for evolving neurological deficits. During the first month, ipsilateral severe headache occurred in 89%, neck pain in 36%, ipsilateral cerebral ischaemia in 82%, ocular ischaemia in 16%, oculosympathetic palsy in 48%, and cranial nerve palsy in 5%. Recent "trivial" head or neck trauma was elicited in 41%. Doppler and duplex sonography confirmed the clinical suspicion of ICD in 91.5% and in 96% of those with a significant stenosis or occlusion. MRI demonstrated a thickened vessel wall in all 33 imaged carotid dissections and a mural haematoma in 30. None of the 32 patients who received anticoagulant treatment subsequently deteriorated. Monitoring anticoagulant treatment with ultrasonographic follow-up studies demonstrated recanalization in 70% and persistent occlusion in 30%. The results demonstrate that familiarity with the initial symptoms, especially headache, and performance of an ultrasonographic study without delay are the cornerstones of an early diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

The sympathetic innervation of the eyes and face: a clinicoanatomic review

Most of the details regarding the course of the sympathetic fibers to human ocular structures are based on anatomical and physiological studies in lower animals. While studying a clinical problem involving pericarotid sympathetic fibers, it became obvious that these animal observations cannot adequately explain the findings in human diseases affecting these pathways. An attempt was made, therefore, to clarify this situation. We were able to gather enough information from human clinical and experimental studies, from our own clinical observations, and from our cadaver dissections to conclude that these pathways are somewhat different from those which are usually described in the literature. Based on this information, we conclude that 1) the oculosympathetic fibers in man do not course through the tympanic plexus and/or trigeminal ganglion, and 2) the sweat glands of the face receive their innervation from both internal and external carotid sympathetic plexuses. We also have suggestive, but inconclusive, evidence regarding the final mode of distribution of these fibers to the dilator of the pupil and the smooth muscle portion (deep layer) of the levator palpebrae superioris muscle (superior tarsal muscle).

Pupillary abnormalities due to sympathetic dysfunction in different forms of idiopathic headache

Idiopathic vascular-type headache is frequently associated with pupillary alteration, which is often presumed to be due to malfunction of the sympathetic nervous system. In this review the anatomical and neurotransmitter basis of oculosympathetic function is briefly discussed along with some of the common pharmacological and physiological pupillary tests used in its assessment. The clinical and subclinical features of the pupil abnormalities are analysed in idiopathic headache, which includes migraine, tension headache, cluster headache, and chronic paroxysmal hemicrania. Possible mechanisms underlying these alterations are suggested. Among secondary headaches, carotid dissection and aneurysm have to be excluded when unilateral headache is associated with a persistent ipsilateral oculosympathetic deficit. From the literature, specific responses to pupillary tests apparently are present in idiopathic headache. Pupillary tests may differentiate between the subtypes of idiopathic headache. The investigation of pupillary dysfunction may provide information on the physiopathological basis of headache.

Headaches in the elderly

Headache prevalence and etiology vary dramatically with age. The prevalence of primary headache disorders, such as migraine and cluster, declines with age, while the prevalence of secondary headache disorders, such as temporal arteritis and mass lesions, increases. In evaluating elderly patients with new onset of headache, a high index of suspicion for organic disease is required. Headache symptomatology also varies with age. For example, migraine may evolve into a pattern of chronic daily headache, or auras may occur in the absence of headache (late-life migraine accompaniments). A careful longitudinal headache history is therefore important. Headache management is also influenced by age. Elderly people are more susceptible to medication side effects and are often treated with several drugs. Medications may cause headaches and drug interactions may complicate therapy. For these reasons, age of onset and duration of illness are critical headache features that guide the subsequent approach to diagnosis and treatment.

[Intracranial dissecting aneurysms of the posterior circulation: report of 3 cases and review of the literature]

Dissecting aneurysms of cerebral arteries are unusual causes of stroke. The carotid system is the commonest site of this pathology, the vertebral arteries are less involved and dissection of the basilar artery is rare. The authors report three cases of arterial dissection of the vertebrobasilar system, two of the vertebral arteries and one of the basilar artery. An extensive review of the literature is presented. The clinical picture of dissection of vertebrobasilar system was inespecific but pain was a prominent symptom, though had not occurred in the site of the arteries involved. The pain was suggestive of subarachnoid hemorrhage. Associated or risk factors were mild trauma, migraine and high blood pressure. The angiographic findings were suggestive, however just the "double lumen" has been considered pathognomonic. The prognosis is variable. It was benign in case 3, left sequela in case 2, and case 1 rebleed fatally.

Non-invasive diagnosis of internal carotid artery dissections

Arteriography is thought to be mandatory for the diagnosis of internal carotid artery (ICA) dissection. With the introduction of transcranial Doppler sonography (TCD) and magnetic resonance imaging (MRI), however, this is no longer the case. In 13 consecutive patients with ICA dissections the diagnosis was made by means of non-invasive tests including extracranial and transcranial Doppler sonography, contrast enhanced computed tomography (ceCT), and, in five patients, MRI. Intra-arterial digital subtraction angiography used as the gold standard in all cases was confirmative. Extracranial and transcranial ultrasound findings indicative of the diagnosis could be identified. MRI directly demonstrated the intramural haematoma and the false lumen of the dissected artery. These non-invasive techniques also allowed for repetitive follow up examinations. They were, however, unable to demonstrate false aneurysms in the chronic state. Results show that the diagnosis of carotid dissection can be made by means of cerebrovascular ultrasound and MRI.

Post-endarterectomy headache and the role of the oculosympathetic system

A study was carried out on headache after carotid endarterectomy. A specific type of headache, similar in its characteristics to "cluster headache", occurred on the operative side in 30% of 54 patients, whereas no such headache occurred after extra-intracranial bypass or peripheral vascular surgery. This postoperative headache was not spontaneously reported by 56% of patients unless they were specifically asked about it. Pharmacological pupillary testing performed in 37 patients revealed that a decreased oculosympathetic activity (with or without adrenoceptor supersensitivity) was constantly associated with post-endarterectomy headache. Although this same abnormality was also observed in 54% of the patients without headache, a statistically significant (p less than 0.01) higher prevalence of decreased oculosympathetic responses was found in the patients with headache. The results suggest that damage to the sympathetic plexus due to the surgical procedure is involved in the development of postoperative "cluster-like" headache.

[Raeder's syndrome caused by dissecting carotid aneurysm]

The authors report a case of Raeder's paratrigeminal syndrome and make some comments about the diagnosis: a dissecant aneurysm of internal carotid artery.

Traumatic dissections of the extracranial internal carotid artery

Traumatic dissections of the extracranial internal carotid artery (ICA) in 18 patients aged 19 to 55 years were studied. All had suffered blunt head or neck injury of marked or moderate severity; motor-vehicle accidents were the leading cause of the injury. Delayed focal cerebral ischemic symptoms were the most common presenting symptoms. Less commonly noted was focal unilateral headache associated with oculosympathetic paresis or bruit. Following a head injury, the abrupt onset of focal cerebral symptoms after a lucid interval should raise the suspicion of arterial injury, particularly when computerized tomography fails to show abnormalities that would explain the evolving neurological deficits on the basis of direct trauma to the brain. Unilateral headaches, oculosympathetic palsy, and bruits also help in establishing the diagnosis. Focal cerebral ischemic symptoms may develop months or years after the initial trauma. These delayed symptoms are caused by embolization from a thrombus within a residual dissecting aneurysm. Common angiographic findings, in decreasing order of frequency, are: aneurysm, stenosis of the lumen, occlusion, intimal flap, distal branch occlusion (embolization), and slow ICA-to-middle cerebral artery flow. Although two patients died as the result of massive cerebral infarction and edema and some were left with severe neurological deficits, most made a good recovery. Residual dissecting aneurysms and occlusion seem to occur more frequently with traumatic dissections than with spontaneous dissections of the extracranial ICA.

Painful Horner's syndrome due to spontaneous carotid artery dissection

Spontaneous dissection of the internal carotid artery as a cause of Horner's syndrome has only been recognized in recent years. The authors describe three patients with this condition. Associated symptoms included ipsilateral orbital and frontal headache (3 patients), neck and facial pain (2), amaurosis fugax (1), and dysgeusia (1). The symptoms resolved in all patients within three months, yet oculosympathetic paralysis has persisted. Diagnosis of carotid dissection required cerebral arteriography, and the angiographic features are presented. Patients were treated with platelet antiaggregants, and they have remained neurologically stable during follow-up (mean, 12 months; range, 10-14 months).

Intracranial carotid artery injury in closed head trauma

Six patients with trauma to the intracranial internal carotid artery are reported. One patient died and two are permanently disabled due to ischemic sequelae. The incidence of this complication of trauma is unknown because of the infrequent use of angiography in head-injured patients. The pathology, clinical course, and management of this condition are discussed with reference to the 25 previously reported cases in addition to the six in this series.

Spontaneous dissection of the cervical internal carotid artery

We studied 36 patients (21 women and 15 men) with spontaneous dissection of the internal carotid arteries. The ages of these patients ranged from 21 to 63 years. Focal unilateral headache was the most common symptom. Other common clinical manifestations (in decreasing order of frequency) included focal cerebral ischemic symptoms, oculosympathetic paresis, bruits, light-headedness, and neck pain. Less common symptoms were syncope, amaurosis fugax, scalp tenderness, swelling in the neck, and dysgeusia. Common angiographic manifestations (in decreasing order of frequency) were elongated, irregular, and frequently tapered narrowing of the lumen; abrupt luminal reconstitution (often at the carotid canal); aneurysms; intimal flaps; slow internal carotid artery--middle cerebral artery flow; tapered occlusion; and distal branch occlusions. The incidence of hypertension in these patients was considerably higher than that in the general population. Angiographic evidence of fibromuscular dysplasia was found in 14% of the patients, but atherosclerotic changes were uncommon. Follow-up ranged from 14 to 140 months (mean, 58.5 months). Twenty-three patients with 29 dissected internal carotid arteries were also restudied angiographically. The stenosis of the internal carotid artery either completely resolved or substantially improved in more than 85% of the dissected vessels. About two-thirds of the dissecting aneurysms either resolved or decreased in size. Clinically more than 85% of the patients had an excellent or complete recovery. Recurrence of the dissection or rupture of a dissecting aneurysm was not noted. Despite their disconcerting appearance on angiography, spontaneous dissections of the internal carotid arteries are often associated with a good prognosis.

Spontaneous dissections of the renal arteries in a patient with previous spontaneous dissections of the internal carotid arteries

An otherwise healthy 35-year-old woman suffered spontaneous dissections of both internal carotid arteries. She made an excellent recovery but was left with occlusion of the left internal carotid artery and a residual subcranial dissecting aneurysm of the right artery--both were asymptomatic. Eight years later, spontaneous dissections of both renal arteries occurred. The exact nature of the underlying arterial disease is not clear. Although fibromuscular dysplasia is suspected, other undetermined arteriopathy cannot be excluded.

Spontaneous dissection of the cervical internal carotid artery

Five patients with spontaneous dissection of the cervical internal carotid artery (CICA) are reported. The different patterns of clinical and radiological presentation are described and the frequently benign outcome is underlined. The need for diagnostic angiography is emphasized.

Fibromuscular dysplasia and the brain. I. Observations on angiographic, clinical and genetic characteristics

The angiographic, clinical, and genetic characteristics of fibromuscular dysplasia (FMD) are reviewed in 37 patients (mean age 48 years) selected from a pool of 4000 angiograms of carotid or vertebral arteries. FMD was a neglected pathogenic factor in 28 patients with hemorrhagic or ischemic cerebral lesions. The aneurysms found in 19 patients had conventional appearance and were mainly located in the internal carotid or middle cerebral arteries and on the same side as the most affected cervical artery, which suggests that aneurysms and FMD are pathogenically related. A clinical syndrome is presented where headache, ECG-abnormalities, hypertension, mental distress, tinnitus, vertigo, arrhythmia, TIA, and syncope are frequent components. Hemicrania, sometimes combined with ipsilateral Horner's Syndrome, was found in patients with advanced lesions in the carotid artery of the same side. An associated occurrence of stroke in pedigrees, especially among young and middle aged females, indicates that FMD in the majority of cases in inherited as an autosomal dominant trait with reduced penetrance in males.

Headache

Present views on the cause and treatment of temporal arteritis, trigeminal neuralgia, pain arising from the neck, benign intracranial hypertension, and other headaches of intracranial origin are summarized. The clinical components of migraine are correlated with recent studies of cerebral blood flow, monoamine changes, and the platelet release reaction. Psychological, physiological, and pharmacological management is based on the holistic concept of migraine as an uninhibited protective reaction. Cluster headache is subdivided into three varieties which respond preferentially to different medication. Tension headache may depend more on vascular mechanisms than excessive muscle contraction, but treatment is still directed at behavioral management and relaxation training with the aid of antidepressant therapy.

Raeder's syndrome. A clinical review

The term "Raeder's syndrome," which now seems to mean any painful postganglionic Horner's syndrome, has been used in the past to describe patients with a wide variety of underlying pathology, including such serious lesions as middle cranial fossa neoplasms and such benign conditions as unilateral vascular headache syndromes. The purpose of this review which is based on the literature and some recent experience with 41 cases of Raeder's syndrome, is to help clarify this syndrome and to aid the clinician in its evaluation and treatment. Patients with Raeder's syndrome have been divided into three major groups. In the first group, the painful postganglionic Horner's syndrome is associated with multiple parasellar cranial nerve involvement and these patients require full neuroradiological investigation to uncover such lesions as local or metastatic tumors within the middle cranial fossa. The second and third groups do not have the multiple cranial nerve damage and their prognoses are benign. The characteristics, clinical investigation and medical therapy of each of these two benign groups are outlined and discussed. Extensive neuroradiological investigation is not recommended for patients in the second or third groups. Common to all three groups of Raeder's syndrome is the association of unilateral headache with the interruption of the postganglionic oculosympathetic fibers along the course of the internal carotid artery.