Bilateral Carotid Artery Dissection After a Fall: A Case of Horner Syndrome Revealed on Examination

Carotid artery dissections are uncommon but critical vascular injuries. They involve a tear to the intima, the innermost layer of the arterial wall, leading to formation of a false lumen. This false lumen can disrupt blood flow, weaken the wall, and lead to thrombus or rupture of the artery. Carotid artery dissections can occur spontaneously or in the setting of trauma. Traumatic carotid artery dissections (TCAD) are rare and occasionally present with third-order Horner syndrome, characterized by ipsilateral ptosis, miosis, and anhidrosis. The presence of subtle physical exam signs like Horner syndrome reinforces the importance of maintaining a high index of suspicion and obtaining vascular imaging in trauma-related cases. While there have been case reports of bilateral TCAD, these have been rarely reported in the literature.

We present a case involving a 53-year-old female with no significant past medical history who presented to the emergency department after tripping and falling down a flight of stairs. Over three weeks, the patient had persistent tinnitus and right neck pain and, on the exam, was found to have right-sided miosis and ptosis. These exam findings led us to obtain a computed tomography (CT) angiogram of her neck, which revealed bilateral internal carotid artery dissections. The patient was taken for cerebral angiography, which confirmed the diagnosis. A stent was placed in the right internal carotid artery, and the patient was started on aspirin and clopidogrel. The patient was discharged without deficits three days later.

Traumatic internal carotid artery dissection can occasionally result in Horner syndrome and requires CT angiography of the neck and potentially a diagnostic cerebral angiogram to diagnose. This case adds to the limited literature on bilateral TCAD, particularly with a delayed and asymmetric presentation. Horner syndrome in the setting of trauma, while subtle, can suggest a carotid artery dissection. Awareness of such rare presentations is key to early diagnosis and treatment. Clinicians must maintain a high index of suspicion for underlying vascular injury in patients presenting with lesser mechanisms of injury.