A 37-year-old man presented with a 10-day history of periorbital pain of sudden onset. For the previous few days he had noticed a slightly dropped left eyelid and slurred speech. There was no history of trauma and no pain in the neck. On examination, incomplete ptosis with miosis (Horner’s syndrome) of the left eye was apparent. In addition, there was a deviation of tongue to the left, resulting from paresis of the left side of the tongue caused by hypoglossal nerve injury (fig 1).

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Figure 1 Tongue deviation due to paresis caused by hypoglossal nerve injury. Written permission was obtained from the patient for the publication of this photograph.

A left carotid artery dissection was suspected, and three-dimensional angiography showed a dissection with segmental narrowing (fig 2, small arrows) and an associated dissecting aneurysm (large arrow). Low-dose aspirin was prescribed to prevent thromboembolic events. If the aneurysm is still present at 6 weeks follow-up, angiography and endovascular treatment will be considered.

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Figure 2 Three dimensional angiography showing dissection with segmental narrowing.