Growing Evidence about the Relationship between Vessel Dissection and Scuba Diving
A 52-year-old-man presented with headache and homolateral Horner's syndrome which had started 4 weeks previously.\nOn the day after scuba diving in cold water, the patient complained of a considerable and persistent neck pain which irradiated towards the left retroocular region. On the following morning, a left-sided facial edema appeared and lasted for a few days. The persistence of the headache, ptosis and miosis, which increased with the worsening of the neck pain, led the patient to seek a neurological evaluation. The examination revealed only the presence of an incomplete Claude Bernard-Horner syndrome (CBHS). Ultrasonography (US) of the carotid arteries did not show plaques or stenosis of the vessels. The fluid dynamic and velocity were normal. A chest X-ray was performed and revealed the presence of a thickening of the right pulmonary apex and several little nodules in the homolateral superior lobe, which were firstly attributed by the radiologist to an expression of a possible old lesion.\nThe patient's past medical history was characterized by benign arterial hypertension treated with Enalapril (20 mg/day), benign prostatic hypertrophy, tension headache attacks and bronchopneumonia at a young age. In his family, his father had died due to pulmonary cancer; his mother and his younger brother were in good health. He had a 19-year-old son with no medical problems.\nFour weeks after the beginning of the symptoms, the patient was admitted to our department. The neurological examination showed a left Horner's syndrome, with normal direct and consensual response to the light stimulus, and no signs of either fatigability or diplopia in any direction of gaze (fig. ). He also presented with a dysesthesic area in the left side of the head, particularly in the parietal and frontal regions, without a clear distribution in the territory of the V cranial nerve innervation. A left-sided deviation of the tongue, when protruded, was also detected (fig. ). No other neurological alterations were found. Head and neck pain had disappeared.\nA head CT scan was performed, but no abnormalities were detected. Because of the persistence of an incomplete CBHS and the family history of lung cancer, in order to exclude the presence of malignancy, we discussed the chest X-ray findings with a lung specialist, who confirmed the hypothesis that the right lobe nodules were scars of a previous disease. Since these lesions were also contralateral to the CBHS, no further investigations were carried out during hospitalization. A follow-up was recommended.\nThe ophthalmologic evaluation showed only a slight increase of the left eye tone and confirmed the presence of anisocoria with miosis in the left eye.\nDespite the normal US findings, we performed brain and vascular magnetic resonance imaging (MRI), aiming at a better investigation of both intra- and extracerebral circulation and potential parenchymal ischemic lesions. The examination did not show any infarctions. Otherwise, MRI revealed a dissection of the ICA in the precarotid region associated with a pseudoaneurysmatic deformation (fig. ). An aneurysm at the bifurcation of the left middle cerebral artery was also found. Cardiac disease could be excluded by echocardiogram.\nThe patient was treated with anticoagulant therapy (Aspirin 100 mg/day). In a follow-up brain and vessel MRI 1 month later (therefore, 2 months after the beginning of the symptoms), a slight decrease of both the dissection and the pseudoaneurysmatic lesion of the left ICA could be detected (fig. ). Parenchymal lesions were never visible.