Carotid dissection is a common cause of stroke in the young patient and can present with various clinical syndromes or symptoms. These may include stroke or transient ischaemic attack,1ipsilateral ptosis, isolated or multiple cranial nerve palsies,2 carotidynia, hemicrania,3scintillating scotomata, pulsatile tinnitus, or subjective bruit.4 I recently cared for a man who experienced an audible “creaking” sound heard even by his wife in the hours before a right middle carotid artery (MCA) infarct secondary to a carotid dissection. I think that this sound represented the actual dissection.

A forty three year old, right handed lawyer with a presumed viral pharyngitis and severe cough for two weeks duration returned from work at 6 00 pm and began hearing periodic, high frequency, “creaking” sounds in his right …