PMC3250342_01
Bacterial endocarditis and mycotic aneurysm of the left common carotid artery in an 87-year-old woman with acute cerebral infarction. (A) Transfemoral cerebral angiography showing focal severe stenosis (up to 75%) of the proximal left ICA (arrow) and transient vascular spasm in the petrous ICA (arrowheads). (B) Thoracic aortography showing no evidence of stenosis or aneurysm of the proximal common carotid artery. (C) Echocardiography showing a newly visible 6x5 mm valvular vegetation of the non-coronary cusp of the aortic valve (arrow), which was not present in preprocedural echocardiography. (D) Chest CT 26 days after admission showing an incidental 22 mmx20 mm saccular aneurysm 2 cm distal to the origin of the left CCA (arrow). (E) Thoracic aortography three days after chest CT showing a saccular aneurysm in the proximal left CCA (arrow) with mass effect to the lumen of the adjacent proximal CCA (arrowhead). (F) The roadmap image of the left common carotid artery during stent insertion showing proper advancement of an undeployed 10 mmx5 cm polytetrafluoroethylene covered stent-graft across the wide neck of the aneurysm in the proximal left common carotid artery (arrows). (G) The final thoracic aortography after stent-graft implantation revealing complete exclusion of the aneurysm and a widely patent implanted stent-graft (arrows). (H) Follow-up chest CT 12 months after the procedure showing a completely excluded aneurysm, thrombosis within the aneurismal lumen (arrow), and a widely patent stent-graft (arrowheads). ICA, internal carotid artery; CT, computed tomography; CCA, common carotid artery.
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Three days after admission, cerebral angiography showed a focal severe stenosis (75%) of the proximal left ICA without abnormal findings in either common carotid artery (Fig. 1A and B). Three days after the onset of fever, brain MRI showed no newly developed acute lesion, and echocardiography showed a newly visible 6x5 mm valvular vegetation of the non-coronary cusp of the aortic valve (Fig. 1C). Twenty-six days after admission, chest CT, which was performed with the suspicion of the Lt. pleural effusion as the cause of the fever, showed an incidental 22x20 mm thin walled saccular vascular structure located 2 cm distal to the origin of the left CCA suggesting a mycotic aneurysm because of acute development, presence of ongoing fever and inflammatory infiltration around the saccular vascular structure (Fig. 1D). Thoracic aortography showed a saccular aneurysm in the proximal left CCA (Fig. 1E). A 10 mmx5 cm polytetrafluoroethylene covered stent-graft (Hercules Vascular: S&G Biotech, Seongnam, Korea) was deployed within the proximal left CCA across the wide neck of the aneurysm (Fig. 1F). The final thoracic aortography revealed a complete exclusion of the aneurysm and a widely patent implanted stent-graft (Fig. 1G). Follow-up chest CT 12 months after the procedure showed the aneurysm completely excluded and a widely patent stent-graft (Fig. 1H).