The n e w e ng l a n d j o u r na l of m e dic i n e

images in clinical medicine

Internal-Carotid-Artery Dissection
and Cranial-Nerve Palsies

A
45-year-old woman presented to the emergency department 3 days Elena Peltz, M.D.
after the acute onset of severe dysphagia, breathy dysphonia, and earache Martin Köhrmann, M.D.
and pulsatile tinnitus in the left ear. Her medical history was unremarkable. University of Erlangen–Nuremberg
Physical examination revealed leftward deviation of the protruded tongue that was Erlangen, Germany
consistent with a lesion in cranial nerve XII, hypernasal speech and rightward devia-
tion of the soft palate on phonation that was consistent with lesions in cranial nerves
IX and X, and a paralyzed left vocal cord detected on laryngoscopic examination that
was consistent with a lesion in cranial nerve X (see video). Axial magnetic resonance
images of the head and neck were obtained and showed an extracranial dissection
of the left internal carotid artery (see video), with delayed perfusion of the left hemi-
sphere but no evidence of ischemic stroke. The acute onset of cranial-nerve palsies
accompanied by pain in the head, neck, or ear should prompt physicians to consider
a diagnosis of internal-carotid-artery dissection. Most peripheral palsies are associ-
ated with cranial nerves IX through XII. This patient was treated conservatively and
showed complete neurologic recovery at a 6-month follow-up examination.
Copyright © 2011 Massachusetts Medical Society.

n engl j med 365;23 nejm.org december 8, 2011 e43

The New England Journal of Medicine
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