Teaching NeuroImages: A disintegrating rock

Summary

Terminology

Original

  • 75yo F
  • c/c
  • PMH
    • HTN
    • dyslipidemia
    • AFib (warfarin)
  • Ex
    • CT
      • nl
    • L/D
      • INR 3.4
  • +2w
    • S/S
      • anomia
      • Rt facial droop
    • Ex
      • L/D
        • INR 3.2
      • CT
        • multiple calcific emboli
        • atheromatous plaque w/i artic arch

A 75-year-old woman with a history of hypertension, dyslipidemia, and atrial fibrillation on warfarin presented with sudden-onset confusion. A brain CT was read as normal. The international normalized ratio (INR) was 3.4. She was discharged home after resolution of her symptoms. Two weeks later, she presented with sudden-onset anomia and a right facial droop. The INR was 3.2. A new brain CT revealed multiple calcific emboli (figure, B). A CT angiogram showed a large atheromatous plaque within the aortic arch extending into the origin of the brachiocephalic artery (figure, C). Retrospectively, the initial CT already showed a calcified embolus (figure, A). Calcified cerebral emboli are frequently overlooked.1 Underlying sources may carry a high risk of recurrent embolism. Their early identification allows appropriate workup and treatment.

Fig.1

Fig

Brain and vascular imaging (A) Initial CT scan. Arrow points to a calcific embolus. (B) A repeat CT scan shows multiple calcific emboli (arrows). (C) CT angiogram of the neck. Arrows point to a large atheromatous plaque within the aortic arch extending into the origin of the brachiocephalic artery causing a 40% stenosis.