Neuro_CTA_Head/Neck: 34 F, velocardiofacial syndrome, arterial canalization during attempted transvenous pacer placement.

CT ANGIOGRAM NECK WITH CONTRAST:

CLINICAL HISTORY: 34-year-old woman with velocardiofacial syndrome, including complex congenital heart disease, arterial recanalization during attempted transvenous pacer placement.

FINDINGS:

PARTIALLY VISUALIZED BRAIN:

Right ACA small hypodensity concerning for infarct. This hypodensity extends somewhat superiorly to the area of hypodensity adjacent to the right frontal horn seen on 7/17/2015 (2-25).

EXTRACRANIAL ANGIOGRAM:

Proximal great vessels: Catheter directly punctures right-sided ectatic aortic arch with mirror image branching, between the origins of the right common carotid artery and right subclavian arteries, with tip in the distal aortic arch. There is hematoma surrounding the distal aortic arch, no active extravasation is seen. No dissection. Left brachiocephalic artery, right common carotid artery, and the right subclavian artery artery regions are widely patent. Bilateral vertebral artery origins are widely patent, left vertebral artery is dominant.

Right internal jugular pacer lead incompletely visualized.

Cervical vessels: There is early bifurcation of the bilateral common carotid arteries, at the level of the clavicular heads. Calcified atherosclerotic plaque is present at the bilateral carotid bifurcations.

The right carotid artery at the level of the thyroid gland is irregular with surrounding soft tissue stranding. Posterior margin of the common carotid demonstrates a small beak-shaped abnormality concerning for injury. Fluid/hematoma surrounds the right carotid artery.

Visualized intracranial vessels: No flow-limiting stenosis or aneurysm. There is a dominant left ACA.

NECK:

Soft tissues: Mild edema overlying right-sided neck catheter and pacer lead.

Bones: Congenital partial fusion of the T1-T2 vertebral body with hypoplastic intervertebral disc. T2 vertebral body inferior endplate irregularity. Midline sternotomy incompletely visualized, no osseous fusion, superior sternotomy wire intact, second sternotomy wire appears fractured, which is unchanged from prior thoracic CT.

Lung apices: Patchy opacities in the right upper lobe, nonspecific thus suspicious for pneumonia, and mosaic attenuation of the lung parenchyma.

Additional comment: Endotracheal tube appropriately positioned. Enteric tubes incompletely visualized. Pulmonary artery stents incompletely visualized.

IMPRESSION:

1. Right ACA small hypodensity concerning for infarct. Recommend MRI for additional characterization of infarct.

2. Direct catheterization of the right-sided aortic arch with mirror image branching, between the right common carotid and right subclavian origins. Surrounding hematoma without active extravasation. No injury to the carotid artery as clinically questioned. No aortic dissection.

3. The right carotid artery at the level of the thyroid gland is irregular with surrounding soft tissue stranding. Posterior margin of the common carotid demonstrates a small beak-shaped abnormality concerning for injury. Fluid/hematoma surrounds the right carotid artery.

4. Right internal jugular pacer lead incompletely visualized.

5. Patchy consolidations in the right upper lobe, new from 6/30/2015 CT, suspicious for pneumonia.