Images in Cardiovascular Medicine Dysautonomia From Bilateral Carotid Artery Dissection

Summary of Case A 47-year-old right-handed woman with rheumatoid arthritisexperienced symptoms of an apparent upper respiratoryinfection with a persistent cough after the syndrome resolved.After 2 weeks of coughing, she developed persistent head-ache and was found to have new hypertension, which per-sisted for the next month. Magnetic resonance imagingwithout angiography demonstrated a right internal carotidarterydissectionwithoutcerebralinfarction(Figures1and2).Follow-up computed tomographic angiography that dayshowed bilateral distal cervical internal carotid artery dissec-tions, with marked luminal narrowing extending into the skullbase (Figure 3). While being evaluated, she had nausea anddiaphoresis, lost consciousness, and became unresponsive tonoxious stimuli. Although a femoral pulse was present, bloodpressure was unobtainable by sphygmomanometry. She was Figure 1. Magnetic resonance fluid attenuation inversion recov-ery axial image shows a narrowed (arrow) right internal carotidartery flow void surrounded by intraluminal T2 hyperintensity,representing thrombus within the dissected vessel wall. The flowvoid of the left internal carotid artery is not visualized becauseof more severe stenosis arising from the dissection of that side.