Vocal cord palsy resulting from spontaneous carotid dissection

Electric scooter-related triple cervical artery dissection

A 34-year-old female presented to the emergency department with neck pain, dysphonia and dysphagia ten days after a fall from an electric scooter. Subsequent computed tomography of the neck revealed bilateral vertebral artery and unilateral internal carotid artery non-occlusive dissections, which were managed with antiplatelet therapy. This case describes mechanisms of injury, clinical presentation, imaging appearances, and subsequent management of cervical artery dissection.

Isolated hypoglossal nerve palsy from internal carotid artery dissection related to PKD-1 gene mutation

Background

Internal carotid artery dissection has been well recognized as a major cause of ischaemic stroke in young and middle-aged adults. However, internal carotid artery dissection induced hypoglossal nerve palsy has been seldom reported and may be difficult to diagnose in time for treatment; even angiography sometimes misses potential dissection, especially when obvious lumen geometry changing is absent.

Case presentation

We report a 42-year-old man who presented with isolated hypoglossal nerve palsy. High-resolution MRI showed the aetiological dissected internal carotid artery. In addition, a potential genetic structural defect of the arterial wall was suggested due to an exon region mutation in the polycystic-kidney-disease type 1 gene.

Conclusions

Hypoglossal nerve palsy is a rare manifestations of carotid dissection. High-resolution MRI may provide useful information about the vascular wall to assist in the diagnosis of dissection. High-throughput sequencing might be useful to identify potential cerebrovascular-related gene mutation, especially in young individuals with an undetermined aetiology.

Bilateral Internal Carotid Artery Aneurysms at the Subpetrosal Portion with Unilateral Lower Cranial Nerve Palsies: Review and Consideration of Surgical Strategy

BACKGROUND

Symptomatic bilateral extracranial internal carotid artery (ICA) aneurysms at the subpetrosal portion are extremely rare, and their treatment strategy remains unknown.

CLINICAL PRESENTATION

A 42-year-old man presented to our hospital with a 2-month history of sudden onset of hoarseness, dysarthria, and dysphagia. Magnetic resonance imaging, magnetic resonance angiography, and computed tomography angiography revealed extracranial bilateral ICA aneurysms at the subpetrosal portion. The left-sided aneurysm compressed the left-sided lower cranial nerves (IX, X, XI, and XII), whereas the right-sided aneurysm was asymptomatic. We prioritized the treatment of the right-sided aneurysm to prevent bilateral lower cranial nerve deficits. This strategy was used because aneurysm treatment is not guaranteed to cure the left-sided cranial nerve palsies that lasted for 2 months. The right-sided ICA aneurysm was treated with ICA ligation and high-flow extracranial-intracranial bypass using the radial artery as bypass graft. Stent-assisted coil embolization was performed to the left-sided ICA aneurysm after 17 days. The patient showed no right-sided symptoms, and his left-sided symptoms remarkably improved 1 year after surgery.

CONCLUSION

Our unique surgical strategy of prioritizing the aneurysm on the "asymptomatic" side may be one of the best treatment approaches in an extremely rare bilateral aneurysm case.

Unilateral Headache and Hypoglossal Nerve Palsy: A Report of Three Cases

Ipsilateral headache associated with hypoglossal nerve palsy is uncommon and is usually reported to be secondary to internal carotid artery dissection. Herein, we report three idiopathic cases of berign ipsilateral headache with hypoglossal nerve palsy.

Isolated vagus nerve paralysis associated with internal carotid artery dissection

Dysphagia and hoarseness caused by laryngopharyngeal paralysis associated with internal carotid artery (ICA) dissection is rare. We reported a case which recovered spontaneously. A 57-year old man visited our hospital complaining of dysphagia and hoarseness lasting for two weeks. Paralysis of right vocal fold and rotational movement of the posterior pharyngeal wall toward the left side during swallowing were observed. Magnetic resonance imaging was performed under diagnosis of isolated right vagus nerve paralysis, and dissection of the right ICA was revealed. He was treated conservatively, and both of laryngopharyngeal movement and the ICA dissection were improved completely. There is a possibility that laryngeal paralysis caused by ICA dissection has been misdiagnosed as an idiopathic paralysis.

Acute dysphagia associated with aortic dissection: a case report and review of the literature

Thoracic aortic aneurysm and dissection are rare causes of neurologic symptoms as well as of dysphagia. We report on a 58-year-old otherwise healthy male patient who presented with acute-onset intermittent dysphagia, mild dyspnea, and chest symptoms. He was referred to an emergency ENT unit for a suspected peritonsillar abscess but died of a massive aortic dissection and cardiac tamponation a few hours later. This rare condition is discussed in the differential diagnosis of adult acute-onset dysphagia.

[Collet-Sicard syndrome after carotid artery dissection]

Collet-Sicard syndrome is a rare condition, defined as unilateral palsy of the last four cranial nerves. It differs from Villaret syndrome because of absence of sympathetic involvement. Collet-Sicard syndrome is most often caused by skull tumors, carotid artery dissections or head and neck trauma. We report the case of a 57-year-old man who presented palsy of the left lower cranial nerves IX-XII linked to carotid artery dissection after trivial neck injury.

Is it meaningful to preserve a palsied recurrent laryngeal nerve?

Surgeons may assume intuitively that preservation of a palsied recurrent laryngeal nerve (RLN) in patients with preoperative vocal cord paralysis is not meaningful. Here we present our experience in four cases with preoperative vocal cord paralysis, and show that preservation of a palsied RLN may be important in maintaining patients' voice.

PATIENTS

Case 1 is a 54-year-old woman who suffered from a recurrent thyroid cancer disease and right vocal cord paralysis. She was subjected to resection of a locoregional lymph node metastasis on the right paratracheal groove. The right RLN was infiltrated by tumor and was sacrificed during surgery. Surprisingly, her voice weakened postoperatively. Evaluation of the patient showed immobility and mild atrophy of right vocal cord. Cases 2, 3, and 4 are patients with preoperative unilateral vocal cord paralysis and undergoing thyroid or parathyroid surgery. In these three patients, the palsied RLNs were identified and carefully preserved during surgery. These palsied RLNs and ipsilateral vagus nerves were tested with intraoperative neuromonitoring, and an evoked electromyographic activity was elicited. Postoperative evaluation of these three patients showed a steady state of voice and immobility without atrophy of vocal cords.

CONCLUSION

Even on a palsied RLN, a positive electrophysiological response may still be yielded by intraoperative neuromonitoring. This means that there may retain residual innervations in laryngeal muscles. To prevent atrophy of a paralyzed vocal cord, further injury to a palsied RLN should be avoided. Even the palsied nerve should be saved whenever possible.