A 45-year old woman presented to the emergency department with a headache, neck pain, drooping eyelid, constricted pupil, and failure to sweat over her forehead. The symptoms began one day ago, after she did plow pose in an advanced yoga class. She is otherwise healthy and fit, and says she does yoga to relieve frequent neck tension that results from her desk job. She describes the current neck pain as piercing and localized to the left side, which is different from her past neck pain. She describes the latter as a dull, tight pain that occurred on both sides of her neck.
She recently read a news story about a woman who had a stroke while doing yoga, and she is worried that the same thing may have happened to her. She has no past medical history and is not currently on any medications.
Neurological examination is notable for left-sided ptosis, miosis, and enophthalmos.
Chest X-ray and ultrasound of left common and internal carotid arteries are normal. Magnetic resonance angiogram (MRA) reveals extracranial internal carotid artery dissection. Transcranial ultrasound is negative for microemboli to the cerebral circulation.
Symptoms are managed conservatively with aspirin for anticoagulation. On repeat MRA six months later, the internal carotid artery appears normal, suggesting complete resolution of the dissection. However, the Horner syndrome (HS) in this patient remains. Further examination and studies rule out connective tissue disease and other issues that could have caused her condition.
Symptoms of HS include ipsilateral miosis, anhidrosis, enophthalmos (retracted eye), and ptosis of upper and lower eyelids resulting in narrowing of the palpebral fissure. The condition results when sympathetic nerves to the face become damaged, such as from stroke or neck trauma.
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