Multiple Cranial Nerve Palsies in a Patient with Internal Carotid Artery Dissection

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 sudden transient (1-hour) rotatory vertigo associated 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 examination showed a right syndrome of lower cranial nerve palsies with dysphonia, pharyngeal and tongue paresis (IX, X, XII), horizontal nystagmus with the rapid phase on the left (presumably due to the involvement of the cranial nerve VIII) without acoustic impairment, slight left limb sensory disturbances and diminished reflexes – especially of the lower limbs. Magnetic resonance imaging (MRI) of the brain with diffusion-weighted images was performed, and any involvement of the brainstem was excluded. Duplex ultrasound examination was normal. Electromyography and lumbar puncture excluded a neuropathy, while MRI of the pharynx and hypopharynx 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 neuropathy. The ocular fundus was normal. Seven days after admission, because of the occurDear Sir, The incidence of spontaneous cervical artery dissection is approximately 5 per 100,000 per year [1] . It is estimated that internal carotid artery (ICA) dissection is responsible 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 clinically 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).