Over the handlebars … and into the hospital (the answer)

This gentleman has a right Horner’s syndrome – caused by a right carotid artery dissection.

Axial imaging of the blood vessels can pick this up. Here you can see the ring of clot in the vessel wall.

Alternatively, an MR or CT angiogram will demonstrate a narrowed vessel.

This had been missed in the eye department.

Horner’s syndrome (aka oculosympathetic paresis) is characterised by:

partial ptosis – droopy eyelid
miosis – small pupil
apparent enophthalmous – sunken look to the eye, due to narrowing of the palpebral fissure
decreased sweating on the forehead – hardly ever reported and never tested for in practice

Why do you get a sympathetic palsy?

Management is pragmatic and still open to debate.

Most clinicians would commence an anti-platelet agent – aspirin or clopidogrel – for 6 months.

Some might consider warfarin, although (ropey) evidence suggests this is no better than aspirin.

Investigation is with either CT angiogram or MR angiogram – this should show the dissected vessel clearly.

this is an important diagnosis not to miss – there is a risk of stroke if left untreated
there are many other causes of Horner’s syndrome – many benign, BUT…
rule of thumb – painful Horner’s = carotid dissection until proven otherwise