A 24-year old woman presents to the physician complaining of persistent weakness in her left arm, which started one week ago. Now she is not able to take part in her favorite Zumba program due to hand weakness. She also has noticed that she has had a decreased taste sensation and it has affected her appetite. Her taste has suddenly become'' less intense'' 10 days ago. Last month she decided to start a new yoga program in the local gym, since she has desired an additional mental activity combined with her physical exercise. Her vital signs are normal, except for increased reflexes in her left arm. Neurological evaluation is otherwise normal except for hypogeusia being confirmed with a taste test. The patient has a history of Juvenile Myoclonic Epilepsy treated effectively with valproic acid. She is not currently sexually active but has four sexual partners in the past using hormonal and barrier contraception. She has no other medical problems. Her family history includes a stroke of her father at age 67 and seizure disorder in her mother.
The correct answer is: C. Vascular wall tear
This patient complains about a focal neurologic deficit in her left arm and a decreased taste sensation since starting a new yoga class. Strenuous exercises (e.g. yoga involving hyperextension of the neck or other sports with high-risk for cervical trauma) can cause carotid artery dissection, which is one of the most common causes of acute stroke in young patients without common risk factors for cerebrovascular disease (eg. smoking history, hypertension). Although it is observed rarely, hypogeusia could be a presenting symptom of carotid artery dissection. This could be explained by compression of the chorda tympani when an extending hematoma of the internal carotid artery expands in the restricted space of the petrous part of the temporal bone exerting mass effects on the adjacent structures.
Typical symptoms of carotid artery rupture are headache, neck pain, Horner's syndrome, pulsatile tinnitus and focal neurologic deficits. However, the absence of these symptoms in a young patient with focal neurologic deficits should not rule out the presence of possible carotid dissection. Carotid artery dissection could be caused by major and minor neck trauma, or even spontaneously. Other common triggers could be chiropractic manipulation, yoga, sports, fights, strangulation and accidents.
Although certain types of epileptic episodes could present with olfactory aura and subsequent flavor and taste disturbance (Answer A) this patient has a well-managed seizure disorder, which is not associated with olfactory aura.
This patient's seizure disorder is well controlled with Valproic acid. Hypogeusia could be an adverse effect of phenytoin but is not associated with Valproate use. (Answer B)
This female young woman without atherosclerotic risk factors (Answer D) is unlikely to have an atherosclerotic plaque rupture.
Although autoimmune diseases like Systemic Lupus Erythematosus (SLE) can present with stroke-like clinical symptoms, this patient does not have other clinical signs of SLE (rash, arthralgias, oral ulcers, etc). In addition, sudden onset of symptoms after a yoga class makes an autoimmune disease less likely. (Answer E)
Tertiary syphilis can present with stroke deficits. However, this patient has not had symptoms indicating prior stages of syphilis in the past. In addition, she used barrier contraception consistently, which reduces her risk for infection. (Answer F)
High Yield Fact
Carotid artery dissection usually presents with headache, neck pain, Horner's syndrome and focal neurologic deficits. Atypical presentations such as decreased taste sensation, especially if these symptoms are accompanied by common triggers of traumatic dissections, should raise concerns about potential carotid artery wall tear.
- Baumgartner R, Bogousslavsky J. Clinical manifestations of carotid dissection. Front Neurol Neurosci 2005;20:70-76.
- Hulsbomer HB, Steinke W. [Taste disorder caused by carotid artery dissection]. Nervenarzt 2001;72:629-31.