Violent Cough, Slurred Speech, and Ptosis in a Middle-Aged Man

Francesco Brigo, MD; Giampaolo Tomelleri, MD


August 23, 2022


The patient in this case presented with a pattern of sensory loss and weakness on the left side of his body consistent with a lesion involving the right corticospinal and corticobulbar fibers and the primary somatosensory cortex. The most likely diagnosis was an ischemic stroke.

Neurologic examination also revealed ptosis of the right eye with narrowing of the palpebral aperture, miosis in the right eye with a pupil that was reactive to light, and reduced ciliospinal reflex on pinching the right side of the neck. These signs are consistent with a partial Horner syndrome resulting from injury to sympathetic fibers traveling with the internal carotid artery. The sudden onset of neurologic deficits after violent coughing and the presence of pain over the patient's right eye are highly suggestive of a right internal carotid artery dissection.

Conventional angiography was performed because the clinical findings were highly suspicious for an internal carotid artery dissection; this confirmed the diagnosis by showing an abrupt narrowing of the vessel's lumen ("rattail-filling defect"). The hyperdense middle cerebral artery revealed by noncontrast CT scan of the head suggested an occlusion of this artery. Laboratory analysis performed during hospitalization revealed the presence of mild hyperlipidemia. Screening analyses for hypercoagulability and rheumatologic disorders were normal. Transthoracic echocardiography was normal; however, duplex ultrasonographic imaging showed a stenosis in the right internal carotid artery.

Dissection of the internal carotid artery is an important cause of cerebrovascular disease in young adults. One study out of Rochester, Minnesota, showed an annual incidence of 2.6 patients out of 100,000 population. The actual incidence is difficult to evaluate, however, and may be higher because this condition, which may be asymptomatic or have various clinical presentations, may go unrecognized.[1] The incidence appears to have increased since the 1980s, but that is likely due to the availability of better imaging studies.[1]


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