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    Top 5 neuro signs never to ignore


    Pain (e.g., headache, eye pain, face pain, or neck pain) is the most common presenting symptom of a Horner syndrome from a carotid artery dissection but may be absent or variable in severity. The incidence is approximately 2.6 per 100,000 in the United States, and it can occur spontaneously or secondary to trauma.3,22 Most patients experience a positive clinical outcome with resolution or recanalization in 80 percent.23

    Apraclonidine is a direct acting, non-selective alpha-agonist (predominantly alpha-2 activity) commonly used in diagnosing the HS. As a result of denervation hypersensitivity after a HS, a positive apraclonidine test will reverse the anisocoria due to dilation from up-regulation of the post-synaptic alpha-1 effect in the eye with the HS and the normal alpha-2 effect in the fellow eye (which produces slight pupillary constriction). This test has a high sensitivity and specificity.3,22,24

    In the acute ER setting, a CT-CTA of the head and neck to thoracic level (T2) is the preferred initial study, and we do not generally recommend waiting for confirmation with topical apraclonidine.


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    21. Vaphiades MS, Roberson GH. Imaging of Oculomotor (Third) Cranial Nerve Palsy. Neurol Clin. 2017 Feb;35(1):101-113

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