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Competing Interests: Competing interests: None declared.

Competing Interests: The authors report no conflicts of interest.

A 28-year-old man in 2004 was identified with a spontaneous pseudoaneurysm and distal left cervical internal carotid artery (ICA) dissection. The patient was followed conservatively for 12 years with cross-sectional imaging. The patient was initially diagnosed with an acute left ICA dissection, with significant luminal narrowing. Follow-up imaging revealed the dissection was not completely healed, and a small pseudoaneurysm, about 4 mm in size, was formed in the distal left cervical ICA. During the 12-year observation period, the patient's pseudoaneurysm expanded from 4.0 mm to 9.0 mm, and the patient presented with ptosis, anisocoria and myosis. Flow diverter embolisation resulted in a radiographic cure of the pseudoaneurysm and resolution of Horner's syndrome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Distinguishing between central and peripheral causes of vertigo can be challenging not only in an acute setting but also in chronic settings. A thorough review of systems and physical exam can assist providers in differentiating central versus peripheral etiologies and the need for urgent imaging. In this case, a 47-year-old man presented with vertigo, right-sided hearing loss, right-sided headache, and right-sided facial pain that began 4 weeks before while the patient was on a cruise ship. His physical exam findings were notable for anisocoria with right pupil 3.5 and left pupil 4.5, mild ptosis on the right side, positive Romberg test to the right, and Fakuda test with deviation to the right. Urgent magnetic resonance imaging revealed dissection of the right cervical internal carotid artery with a nonocclusive intramural hematoma. This case illustrates the importance of imaging in vertigo patients in which a central etiology is suspected. It further demonstrates that isolated partial Horner's or unilateral headache may indeed be the only presenting sign in a carotid dissection., (© Association of Military Surgeons of the United States 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Carotid artery dissection from rupture of the vasa vasorum is under-recognised. We report the case of a 60-year-old woman presenting to our hospital with a 2-week history of right-sided headache, neck pain, unequal pupils and ptosis after being hit by a wave on the beach. She was diagnosed with painful Horner's syndrome. MR angiogram revealed dissection of the right internal carotid artery with an intramural haematoma without an intimal flap. A diagnosis of carotid artery dissection from rupture of the vasa vasorum was made. Initial antithrombotic (aspirin and clexane) were stopped as she was deemed a low stroke risk with no signs of ischaemia on MR brain. Her clinical course was uneventful with resolution of the intramural haematoma seen on repeat MR angiogram., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

We report four cases of painful Horner's syndrome due to carotid artery dissection. A lesion on oculosympathic pathway causes Horner's syndrome. A painful Horner's syndrome needs a prompt exploration by tomodensitometry or magnetic resonance imaging to exclude carotid artery dissection. Actually, carotid artery dissection leads to stroke or cerebral ischemic symptoms, mainly in the first two weeks. The treatment is based on anticoagulants or antiplatelet agents.

Aim Horner syndrome corresponds to the clinical triad of miosis, ptosis, and facial anhidrosis. These symptoms are related to injury of the oculosympathetic chain. In children, Horner syndrome is classified as congenital or acquired. While the diagnosis is made through clinical examination, there is some debate regarding the use of imaging modalities and the extent of anatomical coverage required. Methods Here, we describe two cases of children with acute Horner syndrome. We then review the literature about the different etiology and discuss the interest of some investigations. Results Case 1: An 8-month-old girl without personal or familial history, has presented a right acquired Horner syndrome without additional signs. Frontal chest radiography and ultrasonography of the neck and the abdomen was first achieved and returned normal. The cerebral and cervical magnetic resonance imaging (MRI) with angiographic sequences performed in a second time was also normal. Finally, an enhanced thoracic computed tomography (CT)-scan demonstrated a mass at the right pulmonary apex. Case 2: A 9-year-old boy without personal or familial history has presented an acute headache with loss of consciousness during a basketball competition. Upon waking up, the child has right hemiplegia, aphasia, and left Horner syndrome. The cerebral CT scan realized in the first line was normal. The MRI with angiographic sequences demonstrated M1 left carotid dissection with homolateral white matter infarction. Conclusion Imaging studies seem critical in delineating the nature and extent of any underlying pathology along the oculosympathetic pathway in children presenting a Horner syndrome. In these patients, a history of trauma or surgery may reduce the need for extensive systemic evaluation. Without such anamnesis, a decision to proceed with further evaluation is made with consideration of the relative incidence of tumor, especially neuroblastoma, or other treatable lesions. In this condition, MRI is the more sensitive and recommended investigation., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To study the prognostic importance of Horner syndrome (HS) in patients with internal carotid artery dissection (ICAD) or vertebral artery dissection (VAD)., Methods: In this observational study, characteristics and outcome of patients with ICAD or VAD from the CADISP (Cervical Artery Dissection and Ischemic Stroke Patients) database were analyzed. The presence of HS was systematically assessed using a standardized questionnaire. Patients with HS (HS+) were compared with HS- patients. Crude odds ratios (ORs) with 95% confidence intervals and ORs adjusted for age, sex, center, arterial occlusion, bilateral dissection, stroke severity, and type of antithrombotic treatment were calculated., Results: We analyzed 765 patients (n = 496 with ICAD, n = 269 with VAD, n = 303 prospective, n = 462 retrospective). HS was present in 191 (38.5%) of the patients with ICAD and 36 (13.4%) of the patients with VAD (p < 0.001). HS+ ICAD patients presented less often with stroke or TIA (p < 0.001), less often had bilateral (p = 0.019) or occlusive (p = 0.001) dissections, and had fewer severe strokes (p = 0.041) than HS- ICAD patients. HS+ ICAD patients had a better functional 3-month outcome than those without HS (ORcrude = 4.0 [2.4-6.7]), and also after adjustment for outcome-relevant covariates (ORadjusted = 2.0 [1.1-4.0]). HS+ ICAD patients were less likely to have new strokes than HS- ICAD patients (p = 0.039). HS+ VAD patients more often had vessel occlusion (p = 0.014) than HS- patients but did not differ in any of the other aforementioned variables., Conclusion: In patients with ICAD, HS is an easily assessable marker that might indicate a more benign clinical course. HS had no prognostic meaning in patients with VAD.

Cervical artery dissection (CeAD) occurs preferentially in the middle-aged, and its annual incidence rate is 2.6 to 3.0 per 100,000.(1) Manifestations of internal carotid artery dissection (ICAD) include ischemic stroke and TIA (>70% of patients), headache, neck pain, Horner syndrome, cranial nerve palsy, pulsatile tinnitus, and, rarely, subarachnoid hemorrhage.(2) Cerebral hyperperfusion syndrome is known to occur after carotid artery revascularization procedures and it is thought to result from the combination of several factors that impair cerebral vascular autoregulatory mechanisms.(3.)

We report a case of spontaneous carotid artery dissection suspected by the appearance of Horner's syndrome. Under medical treatment, the intramural hematoma resolved within 3 months. The patient had an uneventful recovery, without any residual neurologic deficit. Spontaneous arterial dissection is responsible for a hematoma in the arterial wall without significant trauma. The pathogenesis remains unknown. Predisposing factors seem to exist. The clinical presentation is variable mainly due to local compression of adjacent structures which can precede a transient or permanent neurological deficit. The diagnosis is confirmed by Doppler US, CT angiography or magnetic resonance angiography, the best optional investigations. The treatment mainly consists of stroke prevention by anticoagulation versus antiplatelet therapy. The role of surgery and/or endovascular techniques has not yet been confirmed.

A woman aged 31 years presented to the emergency department after a minor head injury. She reported mild headache and a metallic taste in her mouth. Full neurologic examination was remarkable only for left-sided Horner syndrome. Left internal carotid artery dissection was confirmed on magnetic resonance imaging. She was treated with aspirin. Symptoms and signs persisted 3 months later, but there was no additional neurologic deficit. We stress the importance of early detection of Horner syndrome to minimize the risk of disabling stroke.

A 56-year-old woman presented with acute ischaemic stroke with NIHSS 13. She had right eye ptosis and miosis. She and her husband were not sure if her facial features were different than usual. With her consent, we compared her face with her pictures on Facebook. In the absence of any ptosis or miosis in her pictures, she was diagnosed with acute Horner syndrome. Facebook may be a useful tool for the neurologists to define the timing of facial neurological signs.

A 9-year-old girl complained of a sudden severe headache during skiing, there was no previous trauma. She was nauseous, vomited and had weakness of the left arm and leg. She developed a right-sided ptosis, miosis and a contralateral hemiparesis, consistent with Horner's syndrome. MRI showed acute infarction of the right hemisphere caused by a dissection of the internal carotid artery. The patient recovered partially with rehabilitation.

Clinical Case: A 42-year-old man presented with ptosis and miosis in his left eye and a history of headache over the last 20 days. An angioresonance showed dissection of internal carotid artery., Discussion: "Painful Horner's Syndrome" is considered to be a medical emergency due possible onset of an internal carotid artery dissection. We consider that awareness of neuro-ophthalmologic emergencies is very important in the clinical praxis of an ophthalmologist. Multidisciplinary treatment and follow-up of these patients is required., (Copyright © 2011 Sociedad Española de Oftalmología. Published by Elsevier Espana. All rights reserved.)

The diagnosis of Horner syndrome (HS) using apraclonidine eye drops is an alternative to the use of topical cocaine drops. A number of reports have described the efficacy of apraclonidine testing, but there is some debate over its sensitivity in the acute setting. We describe a patient with HS secondary to carotid dissection who had a positive response to apraclonidine 3 hours after the onset of symptoms. The case is made for a larger study of apraclonidine use to determine its true sensitivity and specificity, identify confounding factors, and redefine the criteria for positive testing.

We report a patient with Villaret's syndrome (left hypoglossopharyngeal nerve, vagus nerve, accessory nerve, and hypoglossal nerve palsies and left Horner's sign) caused by internal carotid artery dissection. He had neck pain on the left side, Horner's sign on the left side and paralysis of the left hypoglossopharyngeal nerve, vagus nerve, accessory nerve, and hypoglossal nerve. Brain MRI revealed no signal from the left internal carotid artery and no brain infarction, although a tumor-like lesion was observed in the left internal carotid artery. Subsequent MRI studies revealed intramural hematoma in the left internal carotid artery, and on the basis of this finding, he was diagnosed with internal carotid artery dissection. He received anticoagulant and antiplatelet therapy. His symptoms improved gradually. The symptoms of internal carotid artery dissection are neck pain, Horner's sign, brain infarction, and lower cranial nerve palsy. A characteristic feature in this case was that brain infarction was not observed. Only 3 similar cases have been reported in the past In all these cases, the patients had a good clinical course and showed complete recovery from the symptoms. Compared with western countries, in Japan, carotid artery dissection is rare. Carotid artery dissection should be considered as a differential diagnosis of lower cranial nerve palsy.

Background: Internal carotid artery dissection typically presents with a clear history of blunt cranial-cervical trauma. Presenting symptoms include headache, focal cerebral ischemic symptoms, and oculosympathetic paresis (Horner syndrome). It is usually thought that internal carotid dissection is a serious but infrequent cause of Horner syndrome., Objective: A review of the literature reveals that carotid dissection is under-recognized as a cause of Horner syndrome, and outcome is thought to be compromised by diagnostic delay., Case Report: This case report describes a patient who presented to the Emergency Department with a traumatic Horner syndrome caused by internal carotid dissection., Summary: The etiology, clinical manifestations, diagnostic evaluation, and treatment options of carotid dissection are discussed., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Horner syndrome, in which ptosis, miosis, and anhidrosis occur concomitantly, can arise from injury to the sympathetic nerve pathways anywhere from the brain to the end organs. Incomplete Horner syndrome lacks the sign of anhidrosis. We present a case of incomplete Horner syndrome caused by internal carotid artery dissection and provide a road map of the cervical sympathetic nerves involved in Horner syndrome to explain its etiology. We also discuss the imaging of and therapy for internal carotid artery dissections.

Internal carotid dissection can be responsible for stroke and lead to severe neurological and functional complications. Thus, it must be diagnosed and treated with heparin as soon as possible. Horner syndrome is one of the most usual manifestations of internal carotid dissection. We report the case of a patient who presented with a unilateral non-reactive enlargement of the right pupil that did not last longer than 30 s. As a carotid dissection was not recognized from this atypical symptomatology, magnetic resonance angiography was performed only a few days later when Horner syndrome occurred. It disclosed a dissection of the internal carotid artery ipsilateral from its origin. The evolution and the duration of the pupil involvement suggest that the initial episode of mydriasis was caused by an oculosympathetic spasm, a rare form of sympathetic dysfunction that can be observed when the sympathetic nerve or the pericarotid plexus is irritated. It is important to recognize this oculosympathetic spasm because it has equal value as Horner syndrome for the diagnosis of internal carotid dissection., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Horner syndrome, a triad of ptosis, anisocoria, and anhidrosis, results from interruption in the oculosympathetic pathway. It is classically described as either congenital or acquired to depict its underlying pathophysiology and requisite work-up. We report a case of a 10-month-old infant presenting with an acute onset of left Horner syndrome secondary to a spontaneous extracranial internal carotid artery dissection. To the best of our knowledge, this is the first case report in the literature of acute onset of acquired infantile Horner syndrome in association with spontaneous carotid artery dissection confirmed with magnetic resonance angiogram., (Copyright 2010 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Background and Purpose: Isolated Horner syndrome without associated cranial nerve palsies or ischemic symptoms is an important presentation of spontaneous internal carotid artery dissection (sICAD). Ultrasound is often used as a screening method in these patients because cervical MRI is not always available on an emergency basis. Current knowledge on ultrasound findings in patients with sICAD presenting with isolated Horner syndrome is limited., Methods: Patients were recruited from prospective cervical artery dissection databases of 3 tertiary care centers. Diagnosis of sICAD was confirmed by cervical MRI and MR angiography or digital subtraction angiography in all patients. Data on Doppler sonography and color duplex sonography examinations performed within 30 days of symptom onset were analyzed., Results: We identified 88 patients with Horner syndrome as the only sign of sICAD. Initial ultrasound examination was performed in 72 patients after a mean time interval from symptom onset to examination of 11 (SD 8) days. The overall frequency of false-negative ultrasound findings was 31% (22 of 72 patients). It showed stenosis >or=80% or occlusion in 34 (47%) patients, and stenosis

The case is presented of carotid artery dissection causing Horner's syndrome in a 25 year old woman after treadmill running. She presented with characteristic eye signs and mild pain. Early diagnosis and treatment was associated with no long term, serious complications. It is now recognised that carotid artery dissection is more common than previously thought. Better imaging of the carotid artery has facilitated the diagnosis, and it is now essential to rule out this potentially fatal condition in patients presenting with postganglionic Horner's syndrome. It is accepted that relatively trivial trauma can cause a carotid artery dissection, and many sporting activities may place young, fit, healthy people at risk.

A 5-month-old infant had right Horner syndrome and left hemiplegia. Magnetic resonance imaging confirmed smaller cerebral hemisphere and magnetic resonance angiography showed reduced blood flow in the internal carotid artery on the right. A diagnosis of congenital hemiplegia and carotid occlusion secondary to maternal trauma during pregnancy was made.