Case 368 · ICHD-3 6.5.1.1
6.5.1.1 Acute headache or facial or neck pain attributed to cervical carotid or vertebral artery dissection
- Origin
- Synthetic
- Language
- English — also available in German
- Contributed by
- Imported case — HeadAI synthetic vignettes (de Andrade JBC, da Silva Costa TB, Vasconcelos JL, Lopes TLM, Balsells MD, Cristofolini VL, Querobin SO, Filho FMR. Validation of an AI-based platform for structured diagnosis of headache disorders using ICHD-3 criteria. BMC Neurology 25, 489 (2025). doi:10.1186/s12883-025-04473-1. Dataset: Andrade J. Head.AI Platform. Mendeley Data, V2 (2025). doi:10.17632/4fms6cw2s5.2)
Anamnesis
History: A 45-year-old male patient, previously healthy, reports a sudden onset of intense, "stabbing" left lateral cervical pain radiating to the ipsilateral temporal region, 24 hours ago. The pain occurred spontaneously during physical activity (weightlifting). It was associated with vestibular symptoms (dizziness) and transient syncope. He denies any prior cervical trauma or recent infections.
Physical/Neurological Examination:
Ipsilateral Horner's syndrome (mild ptosis, miosis, and anhidrosis).
Carotid bruits on auscultation in the left upper cervical region.
No focal motor or sensory deficits.
Complementary Exams:
Magnetic Resonance Angiography (MRA): Confirms dissection of the left cervical carotid artery with pseudoaneurysm and >50% luminal narrowing.
Cervical Doppler Ultrasound: Turbulent flow and "double lumen" image compatible with dissection.
Report this case — e.g. suspected re-identification risk.