Cerebral Arterial Embolism From a Protruding Atheroma of the Aortic Arch After a Nonpenetrating Chest Trauma
A60-year-old bricklayer was referred to our hospital because of acute bilateral blindness, vertigo, and bifrontal headache occurring within 10 seconds after a violent shock to the right shoulder while he was trying to open a closed door. On physical examination, the patient presented with bilateral tubular vision and strabismus with diplopia consistent with the clinical diagnosis of a “top of the basilar” syndrome. This syndrome is generally associated with an acute transitory embolic occlusion at the bifurcation of the basilar artery with consequent possible ischemia in the mesencephalic and occipital region. Extensive investigations to detect possible embolic causes (duplex-ultrasound; magnetic resonance angiography of the carotid, vertebral, and basilar arteries; transthoracic echocardiography) were negative.
Transesophageal echocardiography, however, showed multiple atheromatous plaques of the aortic arch with mobile peduncles (Figure 1⇓, arrows). Spiral CT confirmed the presence of atherosclerotic plaques of the aortic arch, one located opposite the left subclavian artery (Figure 2⇓).
Virtual endoluminal reconstruction by magnetic resonance angiography shows the roof of the aortic arch with the origin of the left subclavian artery and left common carotid artery and their relationship with the plaques (Figure 3⇓).
The causal link between the pedunculated mobile plaques and the cerebral embolism cannot be definitively proved. Nevertheless, the temporal relationship between the shock to this overweight patient and the neurological sequelae in the area supplied by the basilar artery strongly suggest that the nonpenetrating chest trauma may have caused embolization of the large protruding atheroma lying just opposite the left subclavian artery.
This unique case confirms the importance of the thoracic aorta as a possible source of arterial embolism and the crucial role of transesophageal echocardiography as well as the complementary role of new diagnostic techniques, such as magnetic resonance and spiral CT, for the diagnosis of this condition.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke’s Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
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