By vgreene, 10 February, 2017

ACEP

(BMJ)—A 68-yo woman w/ hx of migraine presented w/ a gradually worsening L temporal headache x10 days. Meds: sumatriptan. Exam: vital signs normal; L TMJ tender; temporal arteries pulsatile and nontender. Labs: ESR and inflammatory markers normal. Head CT negative. LP normal. Three days after admission she developed L tongue swelling and difficulty eating. Exam: L tongue swelling/deviation; dysarthric speech. What is the dx?
Carotid artery dissection
Temporal arteritis
Atypical migraine
Venous sinus thrombosis
Trigeminal neuralgia
You are correct. Magnetic resonance angiogram (MRA) confirmed the dx of internal carotid artery (ICA) dissection, which is only rarely assoc w/ isolated hypoglossal nerve palsy. Furthermore, tongue swelling is a rare finding w/ hypoglossal nerve palsy. This pt was initially treated w/ steroids for presumed temporal arteritis, then switched to aspirin once dissection was diagnosed. Repeat MRA 6wk later showed slight improvement in the L ICA. Her speech eventually improved and she developed no new neurological deficits. Given her increased risk of cerebral ischemia, she was advised to stop taking sumatriptan.

BMJ 2014;349:g5602