A 42-year-old man presented with a 20-day history of homolateral headache that progressively worsened over the past few days.
The patient had a history of hypertension of years of evolution, which was treated by her bedside doctor.
The examination showed uncorrected visual acuity of 20/20 in both eyes with intraocular pressure of 12mmHg in their right eye (OD) and 15mmHg in their left eye (LE).
The extrinsic ocular movements are conserved, calling attention a ptosis of the left upper eyelid of 3mm with adequate function of the elevator muscle.
It also presents anisocoria with a pupillary diameter of 5mm in the RE and 3mm in the LE.
Cocaine was tested by instilling 4% cocaine once in each eye.
The lack of pupillary dilation of the left eye (with adequate dilation in the right eye) 45 minutes after the instillation of the eyedrops inhibits the diagnosis of a Horner's syndrome, because it stops a nerve,
Like the lack of pupil dilation, the ptosis of the affected eye does not change with the cocaine test, a result that also guides us to Horner syndrome.
An angioresonance (ARM) reveals a dissection of the left carotid artery with significant vascular stenosis of 1.5cm in length.
Based on the clinical findings with involvement of the left carotid artery and the results of the studies, the diagnosis of spontaneous carotid dissection is reached and systemic hypotensive treatment, anticoagulation with acenocoumarol, analgesia and treatment are prescribed.
Despite adequate control of blood pressure and blood levels within the therapeutic range, the patient evolves without changes in the neurological examination, resulting in a decrease of control vessel stenosis (MRS) in an 80% reduction of the affected vascular flow at three weeks.
It was decided to maintain the same treatment because it is considered the most appropriate and the patient continues with periodic controls, showing a progressive improvement of the clinical picture during the following weeks.
Five months after the first consultation, in a new resonance the thrombus has reabsorbed considerably, being currently the decrease of 20% and the current occurrence of Horner's syndrome.
