Morning Quiz ☕️ 

17-year-old male
Past Medical History: Marfan syndrome, seasonal allergies
Mechanism of Injury: Fell off a bike, braced with right arm

Presenting Symptoms:

• Acute onset neck swelling and headache (45 minutes prior)

• Left eye drooping (ptosis)

• Intermittent "buzzing sound" (pulsatile tinnitus)

• Left-sided neck mass (3.5 cm)

Physical Exam Findings:

• Vitals: HR 103 bpm, otherwise stable

• Chest: Pectus deformity

• Extremities: Minor lacerations on right upper extremity and left knee

• Neurological:

  • Strength 5/5 in all limbs

  • Fundoscopic exam normal (no papilledema)

• Imaging: Left internal carotid artery 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 🎯: A. Inferiorly directed left lens dislocation

⚙️

Marfan Syndrome (FBN1 mutation)

⬇

Defective Fibrillin-1 → Weak connective tissue integrity (incl. blood vessels, ocular ligaments)

⬇

Predisposition to arterial dissection, lens dislocation

Fall from bike + Bracing with right arm

⬇

Hyperextension or rotational force on neck

⬇

Tear in left internal carotid artery wall (intimal flap)

⬇

Internal carotid artery dissection (ICAD)

ICAD

⬇

Hematoma within vessel wall

⬇

Luminal narrowing → ↓ cerebral perfusion

+

Compression of adjacent structures in carotid sheath

Compression of sympathetic fibers running with ICA

⬇

Partial Horner syndrome

→ Ptosis (Müller muscle denervation)

→ No anhidrosis (sweat fibers run with external carotid)

→ No miosis if central fibers spared

Buzzing (pulsatile tinnitus)

⬇

Turbulent blood flow near ear due to ICA dissection

⬇

Transmission via cochlear structures

Neck mass (3.5 cm)

⬇

Expanding hematoma within vessel wall

⬇

Palpable lateral neck swelling

Headache (acute onset)

⬇

Dissection irritates pain-sensitive structures (e.g., trigeminal, cervical nerves)

⬇

Local referred headache

🧠 Ocular findings in Marfan syndrome

⬇

Zonular fiber laxity (connective tissue defect)

⬇

↑ Risk of lens dislocation

⬇

Typically upward (superotemporal), but can be inferior if trauma shifts zonule balance

⬇

Inferior lens dislocation is plausible in this trauma + Marfan setting

✅ A. Inferiorly directed left lens dislocation → Most consistent additional finding

Differential Table ⚖️

Practice Questions ⏳️ 

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Dr. Shoaib Ahmad