Young Woman With Transient Ischemic Attack and Pulsatile Tinnitus
A 40-year-old female with a history of hypertension and pulsatile tinnitus developed left-sided neck pain and drooping of her left eyelid following a chiropractic manipulation. An hour following the development of these symptoms, she noticed concomitant weakness of her right upper and lower extremities that persisted for fifteen minutes before spontaneously resolving. However, the persistence of her left-sided neck pain and drooping of the left eyelid prompted her to go to the emergency department (ED) for further evaluation. Her past medical history is significant for hypertension and migraine headaches. She is a non-smoker and takes aspirin and losartan. Her blood pressure at presentation was 130/80 mmHg with a heart rate of 60 beats per minute. Her physical examination showed left sided ptosis and miosis. No other neurological deficits were appreciated. MRA of the head and neck revealed a left distal carotid artery and vertebral artery dissection. She also had irregularities in the right carotid and vertebral arteries but no dissection flap was noted (Figure 1). Treatment with heparin drip was initiated and was subsequently bridged to warfarin on discharge. The patient was referred to our Vascular Clinic, where we identified irregularities again in the right carotid and vertebral arteries in addition to recanalization of the left internal carotid artery on follow up imaging (Figure 2).
Which of the following conditions is likely the etiology for her pulsatile tinnitus?