Young patient with isolated tongue deviation.

We describe a case of a 40-year-old white man with a history of transient idiopathic thrombocytopenia. He had no regular medication and worked as a lifeguard. His cholesterol levels were slightly elevated and he smoked 7 cigarillos a day. He did not have a history of obvious head or neck trauma but used to practice martial arts. In his family history, his mother had a cerebral infarction in her 60s. Four days before admission to our emergency room he realized he could not move his tongue to the left side while chewing bread. He visited his primary care physician, who suspected angioedema and prescribed him prednisolone. The medication did not alleviate the symptoms and he gradually developed dysarthria and slight subjective difficulty swallowing food because of difficulty moving his tongue. A few days later the patient went again to see the same physician. He was then sent to a tertiary care unit where an ENT specialist examined the patient and performed endoscopy of the nose, pharynx, and larynx. No peripheral reason for the symptoms was found and he was referred to the neurologist. During clinical examination, the patient had difficulty moving his tongue to the left on protrusion, mild atrophy on the left side of the tongue, and slight dysarthria. A hypoglossal nerve lesion was suspected. He also had subjective feelings of dys-phagia. The neurological examination was otherwise normal. He had no cervical lymphadenopathy or fasciculations of the tongue. MRI of the brain showed old infarctions in the right cerebellum. The brain stem, basal ganglia, liquor spaces, and gray matter were normal. There was no mechanical compression found of the hypoglossal nerve in the brain MRI. The chest radiograph was normal. The laboratory tests including blood count, routine coagulation markers, electrolytes, and creatinine were normal. Thereafter, a MR angiography was performed. What do you expect to be the finding? Answer MR angiography of the neck (Figure) showed dolichoectasia of the left internal carotid artery near the hypoglossal canal, which was a sequela of an older dissection according to the neuroradiologist. This 9-mm dilatation (compared with 4 mm of the normal vessel wall) could have caused hypoglossal nerve compression and the symptoms. The slight dysarthria and dysphagia were caused by impaired motor function of the tongue. According to our written institutional guidelines, we start warfarin in patients with acute carotid dissections; however, because of the chronic nature of the dissection in …