Fax +41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Letter to the Editor Eur Neurol 2007;58:125–127 DOI: 10.1159/000103652 Multiple Cranial Nerve Palsies in a Patient with Internal Carotid Artery Dissection Alessia Mattioni a Maurizio Paciaroni a Paola Sarchielli a Donatella Murasecco a Gian Piero Pelliccioli b Paolo Calabresi a a Neurological Clinic, University of Perugia, and b Neuroradiological Department, Silvestrini Hospital, Perugia, Italy nunciation of the letter ‘S’. The patient also described experiencing a severe dysgeusia without involvement of the motor part of cranial nerve VII and moderate right facial pain. A few days later, the patient had sud- den transient (1-hour) rotatory vertigo as- sociated with nausea and aggravated by head movements. At this time, i.e. 10 days after the first symptoms, the patient was admitted to hospital. Neurological exami- nation showed a right syndrome of lower cranial nerve palsies with dysphonia, pha- ryngeal and tongue paresis (IX, X, XII), horizontal nystagmus with the rapid phase on the left (presumably due to the involve- ment of the cranial nerve VIII) without acoustic impairment, slight left limb sen- sory disturbances and diminished reflex- es – especially of the lower limbs. Magnet- ic resonance imaging (MRI) of the brain with diffusion-weighted images was per- formed, and any involvement of the brain- stem was excluded. Duplex ultrasound ex- amination was normal. Electromyography and lumbar puncture excluded a neuropa- thy, while MRI of the pharynx and hypo- pharynx excluded compressive diseases. During hospitalization, the patient had a sudden, mild reduction in visual acuity in the right eye lasting for 2 days, most likely due to transient ischemic optic neuropa- thy. The ocular fundus was normal. Seven days after admission, because of the occur- Dear Sir, The incidence of spontaneous cervical artery dissection is approximately 5 per 100,000 per year [1]. It is estimated that in- ternal carotid artery (ICA) dissection is re- sponsible for 5% of all ischemic strokes and for 25% of strokes in the young [2, 3]. With ongoing progress in neuroimaging techniques, a wider spectrum of clinical presentations regarding ICA dissection has been reported. In more than 90% of patients, ICA dissection causes carotid territory ischemia, local signs and/or symptoms on the dissection side, whereas the remaining ICA dissections are clini- cally asymptomatic. Cranial nerve palsy is reported in 8–16% of patients having ICA dissection [4]. Here, we report on a patient with right ICA dissection and ipsilateral multiple cranial nerve deficits (cranial nerves II, V, VII, VIII, IX, X and XII). Case Description A 66-year-old obese male, with a his- tory of hypertension and past smoking, had subacute compressive moderate/ severe right temporal-parietal-occipital headache a few days after the flu, with fre- quent sneezing and persistent cough. A few days after headache onset, the patient ex- perienced transient difficulties in chewing and whistling, tongue hypomobility and speech problems, particularly in the pro- Received: October 11, 2006 Accepted: January 19, 2007 Published online: June 13, 2007 Alessia Mattioni Neurological Clinic, University of Perugia Silvestrini Hospital IT–06126 Perugia (Italy) Tel. +39 075 578 4228, Fax +39 075 578 4072, E-Mail alessia.mattioni@genie.it © 2007 S. Karger AG, Basel 0014–3022/07/0582–0125$23.50/0 Accessible online at: www.karger.com/ene rence of this new ocular symptom, MRI was repeated with contrast-enhanced MR angiography (MRA). MRA showed a mod- erate reduction in the right ICA lumen from the origin with an extension to the cranial basis (carotid canal) (fig. 1a). Up until the carotid canal, MRI with T 1 and fat subtraction images revealed a hyperin- tense signal surrounding the narrowed lu- men of the artery (fig. 1 b). Subsequently, the patient has been treated with 300 mg of aspirin per day and completely recovered from clinical symptoms after a few days. MRI performed 3 months after the onset of symptoms showed complete recanaliza- tion of the ICA. To date, 1 year later, the patient remains asymptomatic. Discussion Cranial nerve palsy can be present in more than 10% of patients with spontane- ous dissection of the ICA [5, 6], and the lower cranial nerves IX–XII are most com- monly affected, particularly the hypoglos- sal nerve. The involvement of various combinations of nerves has also been de- scribed [5, 7], but involvement of a large number of cranial nerves is very rare. The possible explanations for cranial nerve in- volvement are: stretching or mechanical compression by intramural hematoma of the dissected artery, interruption of the nutrient arteries supplying the cranial