Morning Quiz ☕️ 

17-year-old Male came to Emergency department with -

Presenting complain: Acute onset neck swelling and headache (45 minutes prior to arrival)

Mechanism of Injury:

• Fell off a bike after hitting a curb

• Braced fall with right arm

Medical History: Marfan syndrome, seasonal allergies

Initial Assessment

Vital Signs:

• Heart rate: 103 bpm

• Otherwise stable

Physical Examination:

• Chest: Pectus deformity, otherwise unremarkable

• Extremities:

  • Right upper extremity and left knee: Minor lacerations

  • Muscle strength: 5/5 in upper and lower extremities

• Neck:

  • Left-sided 3.5 cm neck mass

  • Cervical spine collar placed for immobilization

• Eyes:

  • Left eye drooping

  • Fundoscopic exam: Unremarkable, no optic disc edema

• Neurological:

  • Intermittent buzzing sound reported by patient -not heard by staff

Imaging Findings

• Diagnosis: Left-sided internal carotid artery (ICA) dissection

  

Question

Which of the following additional findings would be most consistent with this patient’s presentation?

Options:
a. Inferiorly directed left lens dislocation
b. Left-sided deviation of the tongue
c. Fasciculations of left gastrocnemius muscle
d. Significant atrophy of the tongue musculature
e. Bilateral abducens nerve palsy

Correct Answer 🎯: B. Left sided deviation of the tongue

⚙ Hypoglossal nerve (CN XII) ischemia ipsilateral to the dissection → weakness of the ipsilateral tongue muscles → tongue deviates toward the weak side (left).

🧠 Key insight: This is a classic finding in hypoglossal nerve palsy due to carotid artery dissection.

⚙️

 Marfan Syndrome (Underlying Condition)

⬇

⚙ Mechanism: Defective fibrillin-1 → weak connective tissue (like a frayed rope 🪢).

⬇

🧠 Weak connective tissue makes blood vessels fragile, like a worn-out hose.

⬇

Trauma (🚴 Bike Accident)

⬇

Fall with right arm bracing → mechanical stress on neck vessels (like a sudden tug on the frayed rope 🪢).

⬇

🧠 Trauma can tear fragile vessels, especially in Marfan syndrome.

⬇

Internal Carotid Artery Dissection (Left Side)

⬇

Tear in the arterial wall

⬇

Intramural hematoma → Apparent Neck Mass (3.5 cm) (The Visible Bump)

⬇

Narrowing of the vessel lumen(like a kink in a hose 🚿).

⬇

Dissection reduces blood flow downstream, causing ischemia.

⬇

 Ischemia of Cranial Nerves and Brain Regions

⬇

↓ Blood flow to hypoglossal nerve (CN XII) → left-sided tongue deviation (like a deflated balloon 🎈 on the weak side).

⬇

🧠 CN XII ipsilateral to the dissection is affected, causing tongue deviation toward the weak side (left).

⬇

↓ Blood flow to oculomotor nerve (CN III) → left eye drooping (ptosis) (like a broken pulley 🏗️).

⬇

🧠 CN III supplies levator palpebrae superioris; ischemia causes ptosis.

⬇

↓ Blood flow to temporal lobe or auditory pathways → intermittent buzzing sound (tinnitus) 

⬇

🧠 Auditory hallucinations can result from ischemia in auditory processing areas.

Neck Swelling and Headache

⬇

Hematoma formation at the dissection site → neck swelling (like a balloon inflating 🎈).

⬇

⚙ Stretching of arterial wall → acute headache (like a rubber band snapping 🪀).

⬇

🧠 Key insight: These are classic symptoms of carotid artery dissection.

⬇

Tachycardia (Heart Rate = 103 bpm)

⬇

 Pain and stress response → sympathetic activation → ↑ heart rate 

Differential Table ⚖️

Practice Questions ⏳️ 

Most Importantly Solve UWorld Questions with IDs:

105531, 12155, 19802

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Dr. Shoaib Ahmad