A 66-year-old man without significant medical history developed spontaneous sudden-onset left-sided headache. Pain started deeply behind the left ear and quickly spread upward into the head and face on the entire left side up to midline. Pain was controlled with analgesics and pregabalin. Ten days later, he noted that his tongue was swollen and he occasionally bit his tongue on the left side. Clinical examination showed dysarthria, deviation of the tongue to the left, left ptosis, and miosis consistent with hypoglossal palsy and oculosympathetic paresis (Figure, A and B). Magnetic resonance angiography showed carotid dissection in the subcranial segment that compressed the hypoglossal nerve after exit from the hypoglossal canal (Figure, C). The lumen was compromised, suggesting intimal tear. The cause of carotid dissection was not established. He was treated with anticoagulants.
Pikija S, Unterkreuter P. Ipsilateral Hypoglossal and Oculosympathetic Paresis in Carotid Dissection. JAMA Neurol. 2014;71(8):1050. doi:10.1001/jamaneurol.2013.6378