Right-sided aortic arch with mirror image branching

Case contributed by Dr Yair Glick

Presentation

Suffered from dizziness of several minutes' durationfirst thing in the morning. Same ordeal at the ER, tends to topple over to the right, difficulty walking.

Patient Data

Age: 85 years
Gender: Male

NCCT head:
No evidence of intracranial bleed, acute infarct, or mass effect. Preserved midline.
Dilated ventricles. Sulci and basal cisterns of normal width for patient's age.
Mild subcortical and periventricular leukoaraiosis.
Bilateral pseudophakia.

The intracranial arteries and neck arteries show no narrowing or irregularity.
Aplasia of right PCom. PICA termination of hypoplastic left vertebral artery.
Right-sided aortic arch with mirror image branching.
Hardly any atherosclerosis.

 

Just for completing the picture - chest x-ray taken on same day, after the CT study, shows a right-sided aortic arch and a large hiatal hernia containing an air-fluid level.

Case Discussion

An octogenarian with cardiovascular risk factors presented with vertigo-like dizziness. A vestibular source was ruled out clinically. No focal neurological deficit. Referred for CT head and CTA head and neck - vertebrobasilar insufficiency?

Not only did CTA not reveal any stenosis, but his neck arteries and intracranial arteries were extremely well-preserved for his age (i.e. almost entirely devoid of atherosclerosis). He did, however, have two concurrent developmental variants that rendered his posterior circulation tenuous: aplasia of the right PCom and PICA termination of a hypoplastic left vertebral artery.

Incidental finding of right-sided aortic arch with mirror image branching; the order of vessel takeoff from the aortic arch is as follows: left brachiocephalic artery, right common carotid artery, right subclavian artery.

 

 

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