A 57-year-old man presented with dysphonia, severe parietal headache, nausea and dysphagia for solid food, appearing sequentially over the course of 10 days. He reported pain and tumefaction on the right side of the neck. Right-sided gag reflex was absent and there was an asymmetrical right palatal and vocal cord paresis, trapezius muscle wasting and hemi-tongue fasciculations. There were no signs of Horner syndrome. Initial axial head computed tomography scan and brain magnetic resonance imaging (MRI) did not disclose any remarkable changes, but further investigation with MRI angiography revealed a distal right internal carotid artery (ICA) dissection (Figure 1). The patient referred hunting as a hobby. A color duplex sonography of the cerebral arteries was performed and besides a small asymmetry on distal ICA caliber, there were no signs of stenosis, occlusion, hypoechogenic wall hematoma, false lumen, hyperechogenic flap, or pseudoaneurysm (Figure 2).
Figure 1.
Magnetic resonance (MR) angiography. Axial T2-weighted magnetic resonance imaging (MRI) sequence (A) and axial T1-weighted MRI sequence (B) after injection of gadolinium-based contrast medium showing eccentric, hyperintense crescent-shaped mural hematoma along the lateroposterior right internal carotid artery (ICA) wall (arrows); (C) Coronal T2-weighted MRI sequence after gadolinium depicting right ICA subadventitial dissection sparing the carotid bulb and extending to C1 to C2 level, without significant vessel lumen narrowing (arrow).
Figure 2.
Ultrasound findings (morphologic and hemodynamic signs). A, Distal right internal carotid artery diameter measurement (0.4 cm); (B) Left distal internal carotid artery diameter measurement (0.6 cm); (C) Peak systolic flow at distal right internal carotid artery (66 cm/sec); (D) Peak systolic flow at distal left internal carotid artery (77 cm/sec).
Collet-Sicard syndrome (CSS) is a rare clinical entity characterized by lower cranial nerves IX to XII palsy, sparing the sympathetic fibers, resulting from lesions at the base of the skull that affect both the jugular foramen and hypoglossal canal.1,2 There are several known causes of CSS, the most common of which are trauma and neoplasms of the ear and skull base.3 Carotid artery dissection, as in our patient, is a rare cause.4 In the absence of a major traumatic injury, we identify the minor repetitive trauma associated with the shooting rifle against the shoulder, causing direct mechanical stress to the artery, as the likely cause of the dissection in this patient.
Footnotes
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Verónica Cabreira, MD 
https://orcid.org/0000-0001-9945-7681
References
- 1. Collet FJ. Sur un nouveau syndrome paralytique pharyngo-larynge par blessure de guerre (hemiplegie glosso-laryngo-scapulopharyngee). Lyon Med. 1915;124:121–129. [Google Scholar]
- 2. Sicard JA. Syndrome du carrefour condylodechire posterieur (type pur de paralysie des quatre derniers nerfs craniens). Marseille Med. 1917;53:385–397. [Google Scholar]
- 3. Barbiero FJ, Baehring JM, Fulbright RK, Becker KP. MRI findings in Collet-Sicard syndrome. Neurology. 2017;88(8):811. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Mokri B, Silbert PL, Schievink WI, Piepgras DG. Cranial nerve palsy in spontaneous dissection of the extracranial internal carotid artery. Neurology. 1996;46(2):356–359. [DOI] [PubMed] [Google Scholar]