Postcoital artery dissection is a rare condition. Here we report a 40-year-old male patient with painful Horner syndrome related to postcoital internal carotid artery (ICA) dissection. In neurologic examination of the patient, semiptosis, enophthalmus, and myosis were observed on the left side. There were no carotid bruits. On T1-weighted and fat-suppressed cranial MRI, hyperintensity consistent with intramural hematoma was observed within cervical and temporal petrous segments of left ICA. On cervical and cranial MRA, marked decrease in the calibration of C1 and C2 segments of the left ICA was remarkable. The patient was diagnosed as left ICA dissection and anticoagulant therapy was initiated. A prominent improvement was noted in clinical findings during two months of followup period.
Carotid artery dissection is characterized by the formation of mural hematoma as a result of rupture of tunica intima with an incidence of 2.5–3/100.000. It can develop spontaneously or secondary to trauma. Although postcoital artery dissections are rarely reported in the literature, any incident of postcoital carotid artery dissection in patients presented with isolated Horner syndrome has not been encountered so far [
A 40-year-old male patient was referred to our outpatient clinic with complaints of rapid onset of pain localized on behind his left eye during intercourse and subsequent development of ptosis of his left eyelid. Physical examination did not reveal any evidence of abnormality. In neurologic examination, semiptosis, enophthalmus, and myosis were observed on the left side. There was no sweating abnormality on his face. Ophthalmologic evaluation revealed normal visual acuity and intact fundi, bilaterally. There were no carotid bruits. He was smoking a pack per day for 20 years, without any history of alcohol and any known substance and drug abuse. Cranial magnetic resonance imaging (MRI) and craniocervical magnetic resonance angiography (MRA) were performed on the patient with diagnosis of left Horner syndrome. On diffusion MRI, any acute ischemic lesion was not detected. On T1-weighted and fat-suppressed cranial MRI, hyperintensity consistent with intramural hematoma was observed within cervical and temporal petrous segments of left ICA (Figures
(a) Hyperintense area surrounding the left ICA on T1-weighted axial cranial MRI (white arrow). (b) Intramural hematoma on the left ICA on T1-weighted, fat-suppressed axial cranial MRI (white arrow). (c) Marked decrease in blood flow within cervical and temporal petrous segment of the left ICA on cervical MRA (white arrow).
Horner syndrome manifests itself with signs of ptosis, myosis, enophthalmus, and facial anhidrosis. It is characterized by interruption of oculosympathetic pathway at any point between hypothalamus and the eye. Denervations of pupillary dilator and Muller muscle result in myosis and ptosis, respectively. Ciliospinal reflex is lost. Facial flushing can be seen. Since sympathetic fibers responsible for sudomotor innervation diverge from oculosympathetic pathway before superior cervical ganglion, anhidrosis is not seen in postganglionic lesions [
Although patients with spontaneous ICA dissections frequently present with clinical manifestations of stroke, only 20% of the patients seek medical care with local complaints of head and neck pain, pulsatile tinnitus, and symptoms of isolated Horner syndrome. In the literature, in 91% of the cases with Horner syndrome developed secondary to ICA dissection, ipsilateral pains on neck and also headache have been reported. More rarely lower cranial nerve palsies can be seen [
Painful Horner syndrome with carotid artery dissection is a medical emergency in that carotid artery dissection is a serious consideration among its etiologic factors. In patients with Horner syndrome, attentive evaluation of medical history, physical, and radiological examination results is crucial so as to administer optimal and timely treatment and also prevent further deterioration of the patient’s clinical state.
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