6.5.1.1 Acute headache or facial or neck pain attributed to cervical carotid or vertebral artery dissection

Identification: Female patient, 45 years old, previously healthy, with a history of cervical manipulation by a chiropractor 48 hours before the onset of symptoms. Current Illness History: Sudden and intense left unilateral cervical pain (8/10) during chiropractic session. Progression to ipsilateral fronto-orbital headache 12 hours later. Pain Characteristics: Pulsatile/constrictive quality. Exacerbation with cervical movements. Associated with: Partial Horner's syndrome (left ptosis and miosis). Ipsilateral pulsatile tinnitus. Transient amaurosis of the left eye (duration 2 minutes). Neurological Examination: Focal signs: Left Horner's syndrome (2mm ptosis, facial anhidrosis). Absence of motor/sensory deficits (NIHSS=0). Cervical palpation: Pain on palpation of the left carotid artery. Cervical auscultation: Absent carotid bruits. Complementary Exams: Neck MR Angiography: "Double lumen" sign in the left cervical internal carotid artery. Intramural hematoma (thickness 5mm). Luminal stenosis >70%. Non-contrast cranial CT: No evidence of acute cerebral infarction. No intracranial hemorrhages. Cervical Doppler ultrasound: Turbulent flow in the left internal carotid. Increased systolic velocity (320cm/s).