An 85 year-old woman with hypertension and dyslipidemia was admitted with visual impairment, left hemiparesis, and sensory disturbance. A systolic bruit was not audible in her neck or supraclavicular fossa. Magnetic resonance imaging revealed a fresh infarct in the right occipital lobe and magnetic resonance angiography (MRA) showed occlusion of the right posterior cerebral artery (PCA). Carotid ultrasonography showed no stenotic lesions. We performed transesophageal echocardiography (TEE) and found a mobile lesion in the origin of the innominate artery. After several days, we performed real-time three-dimensional (3D) TEE for further evaluation. We found that the mobile lesion was stringy with a length of 2.7 cm and moving in a circle around the point of adhesion. We could also detect the lesion by ultrasonography with a sector probe from the superior thoracic aperture. The lesion could not be detected by cervical MRA or computed tomography angiography.
The patient had no cardiogenic embolic source such as atrial fibrillation or a right to left shunt. There was no abnormal vascular form of dissection or aneurysm. We considered the mobile thrombogenic lesion to have originated from a ruptured atherosclerotic plaque with thrombus.
3D TEE may be a useful method for real-time three-dimensional evaluation of a mobile lesion located in the innominate artery or aortic arch, which is often difficult to evaluate by other methods.
