Abstract 098: Symphony of Risk: A Case Report of Carotid Artery Dissection Associated with Violin Playing

Abstract

Introduction Carotid artery dissection (CAD) is an uncommon and potentially life‐threatening condition that can have a delayed presentation. More commonly associated with blunt cervical trauma, CAD due to repetitive stress to the neck goes under‐recognized, making it challenging to diagnose. Herein, we aim to shed light on a unique instance of CAD after continuous microtrauma, as well as highlight diagnostic challenges associated with CAD. Methods We present a case of a 57‐year‐old man who presented with a one‐week course of unequal pupils, left‐sided headaches, left sided ptosis, and intermittent blurry vision. Exam revealed a callous where he held a violin against his left neck, having endorsed playing for several years with repeated contortion of his head to the left (Figure 1A). Magnetic resonance angiogram (MRA) of the head and neck revealed an acute dissection of the left internal carotid artery (ICA) (Figure 1B). A diagnosis of Horner’s syndrome secondary to acute dissection of the left cervical ICA was made. Consent to share this information was obtained from the patient and witnessed by another physician. Results MRA head and neck showed a 2.5 cm irregularity of the distal left ICA with high signal on fat saturated T1‐weighted images consistent with an acute dissection (Figure 1B). The patient underwent an apraclonidine test and was positive for left sided Horner’s syndrome with reversal of anisocoria after application of drops (Figure 1C). Given no evidence of stroke or thrombus on imaging, he was placed on dual antiplatelet therapy (DAPT) for three months. He was advised not to play violin for a month and to restart cautiously with a pad between his neck and the instrument. Follow‐up imaging showed eventual resolution of the CAD, while physical exam revealed improvement in ptosis and miosis. Conclusion While playing the violin involves repetitive stress on the neck, there is limited research on this specific activity as a cause of carotid artery dissection, making it a rare occurrence. Common clinical manifestations of CAD include neck pain, headache, Horner’s syndrome, tinnitus, stroke, and lower cranial nerve palsies, occurring suddenly or over time. Diagnosing CAD typically involves a combination of thorough history, physical examination, and diagnostic imaging. Ongoing research in the optimal management of CAD focuses on minimizing the risk of stroke, after factoring in variables such as location of dissection and whether it is symptomatic or not.