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A 42 year old man presented acutely with left sided head and neck pain. The next day his symptoms had progressed to involve his tongue, which he considered “swollen”. Examination disclosed a transient Horner’s syndrome and lower cranial nerve palsies involving IX,X,XI,and XII nerves (figs A-C) on the symptomatic side.T2 weighted MR images of the jugular foramen disclosed intramural haematoma (arrow) in the ipsilateral internal carotid artery (fig D) but without compromise of the true lumen of the artery, as confirmed by a normal MR angiogram.
Lower cranial nerve palsies caused by internal carotid dissection are rare. Most ICA dissections occur in the subintimal space and compromise the vessel lumen. However, a small proportion occur in the subadventitial layer, causing haematoma formation with vessel wall expansion into the carotid space.This results in compression of adjacent structures such as the lower cranial nerves without vessel narrowing. As in this case, MR or conventional angiography may be normal.