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Internal carotid artery dissection presenting as hypoglossal nerve palsy

Background: Carotid artery dissection is thought to be a consequence of a tear in the tunica intima, resulting in an intramural hematoma and creation of a false lumen. In such cases, thrombus formation and distal embolization may lead to ischemic stroke. Alternatively, the dissection plane separates the tunica media from the tunica adventitia, resulting in aneurysmal dilatation. This may result in compression of neighbouring structures. The clinical spectrum is diverse making the diagnosis illusive. Yet, carotid dissection is a main cause for strokes in young population, hence the importance of a timely diagnosis in order to minimize complications. Case description: A 49-year-old man was admitted with slurred speech, left-sided head and neck ache and difficulty swallowing. He described an increasing difficulty moving his tongue to the left side. His symptoms began following a mild trauma. On examination, he had mild dysarthria and tongue deviation with difficulty to move the tongue to the left, findings characteristic of left hypoglossal nerve palsy. There was no evidence of Horner’s syndrome or other focal neurological signs. CT brain scan was normal. Vascular imaging revealed left carotid artery dissection with significant mural hematoma. Discussion and conclusions: Lower cranial nerves such as the hypoglossal nerve can be involved due to localized pressure in the neck. The Hypoglossal nerve passes close to the carotid artery hence may be compressed in carotid artery dissection, leading to hypoglossal nerve palsy. Carotid artery dissection accounts for a high proportion of stroke in young people. Carotid artery dissection is frequently associated with neck trauma, such as vehicle accidents, assaults, but can appear even in mild trauma. Usually, clinical suspicion of carotid dissection arises due to focal neurological deficits or Horner’s syndrome. In the case described herein, hypoglossal nerve palsy due to local compression was the main clinical manifestation. When carotid artery dissection is suspected diagnosis through vascular imaging, and prompt treatment are imperative in order to prevent further complications.