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This 45year old woman presented with 10 days of right sided neck and head pain. Figure 1 demonstrates a right Horner’s syndrome, fig 2, taken with the curtains open, demonstrates the oculosympathetic miosis that is more easily seen in the dark. Magnetic resonance angiography of her cerebral circulation confirmed a right internal carotid dissection (fig 3); fig 4 demonstrates a false aneurysm and intramural thrombus. A painful Horner’s syndrome should be considered due to carotid dissection until proved otherwise. The investigation of choice is magnetic resonance angiography of the cerebral circulation but cross sectional imaging should always include the neck to look for intramural thrombus.
Dissection is believed to cause up to 25% of strokes in younger patients, the majority of whom will have warning symptoms that potentially allow a window of opportunity to prevent an infarct. The patient was managed with low molecular weight heparin, then warfarin, and has had no ischaemic symptoms after three months of follow up.