Weakness and Dizziness Answers 395spared. Kehr sign (d)refers to left shoulder pain associated with splenic
rupture. Nikolsky sign (e)is sloughing of the outer epidermal layer with
rubbing of the skin seen in dermatologic diseases, such as pemphigus vulgaris
and scalded skin syndrome.
364.The answer is a.(Tintinalli et al, pp 1387, 1463.)This patient has an
internal carotid artery (ICA) dissectionsecondary to chiropractic neck
manipulation. ICA dissection can occur spontaneously or in minor neck
trauma and should be considered in a young patient with acute stroke.
ICA dissection should also be suspected in patients with neck pain and
Horner syndromebecause of the disruption of ipsilateral oculosympathetic
fibers. In this scenario, it presents with ipsilateral Horner syndrome and
contralateral ischemic motor deficits. Other causes of acute Horner syndrome
includetumors(ie, Pancoast tumor), stroke, herpes zoster infection, and
trauma.
Cavernous sinus syndrome (b)presents with headache, ipsilateral eye
findings, and sensory loss in the distribution of cranial nerve Vā-ophthalmic
branch. Eye findings include proptosis, chemosis, Horner syndrome, and
ophthalmoplegia caused by the involvement of cranial nerve III, IV, and VI. It
does not cause decreased strength in the extremities. MS (c)is an inflamma-
tory demyelinating CNS disease resulting in various neurologic abnormalities,
such as optic neuritis, transverse myelitis, and paresthesias. Transverse myelitis
(d)is a postviral or toxic inflammation of the spinal cord that results in sensory
loss and paresis. An isolated spinous process fracture (e)typically occurs in the
setting of trauma and is considered a stable vertebral fracture. It does not result
in motor weakness.
365.The answer is c. (McIntyre, 2006.) This patient presentswith
vertebrobasilar insufficiency(vertigo) and claudication(atypical arm pain
with exercise), symptoms consistent with subclavian steal syndrome.This
phenomenon occurs in patients with subclavian artery occlusion or steno-
sis proximal to the vertebral artery branch, which causes retrograde blood
flow in the vertebral artery with ipsilateral arm exercise. Collateral arteries
arising from the subclavian artery distal to the obstruction deliver blood to
the arm. During arm exercise these vessels dilate and siphon blood from the
head, neck, and shoulder to increase perfusion of ischemic arm muscles.
This results in temporary reversal of blood flow in the vertebral arteryleading
to vertebrobasilar insufficiency and symptoms of vertigo, dizziness, syn-
cope, dysarthria, and diplopia. Arm pain is a result of muscle ischemia.