The stimulation of the hypersensitive baroreceptors in the carotid sinus can lead to bradycardia, vasodilation, and hypotension. This has been described during carotid massage or during angioplasty of the carotid. We present a patient with a left internal carotid artery (ICA) dissection resulting in concurrent profound hypotension and bradycardia, not related to external massage or insular mediated arrhythmia, that improved after stenting.

A 35-year-old postpartum woman presented with acute right arm weakness to the emergency department 5 hours since her symptoms began. Computed tomography (CT) angiogram of her head showed a left ICA dissection with 90% stenosis. She subsequently developed right facial droop, non-fluent aphasia and worsening right sided weakness. Heparin infusion was started. Her systemic blood pressure (BP) began to decrease with systolic ranges below 90 and required vasopressor support. She also had sinus bradycardia in the range of 30-40. Magnetic resonance imaging of the brain showed acute watershed zone infarctions of the left hemisphere. Ultimately, she underwent left ICA stenting and was transitioned to aspirin and ticagrelor. She was gradually weaned off vasopressor support and able to tolerate normotensive ranges without symptomatic deterioration. On discharge, her systolic BP ranged 95-110 and pulse rate in the 80s. Most of her symptoms had resolved with residual mild right facial weakness. The left ICA dissection was likely secondary to recent childbirth.

We present the rare case of simultaneous acute hypotension and bradycardia due to a unilateral internal carotid artery dissection. We suspect this is due to pressure from organized thrombus in the carotid that was alleviated after stenting. This case highlights the importance of close telemetry monitoring and blood pressure management within this population to prevent expansion of ischemic burden and worsening symptoms.