CASE

A 47-year-old African-American woman presented to the emergency department (ED) with right-sided weakness and what she described as feelings of “heaviness” in the right leg. She also complained of mild abdominal discomfort. These symptoms had been present for a few days. Her history was significant for smoking one pack of cigarettes per day for 25 years, and she also had a history of gastroesophageal reflux disease and arthritis. She denied shortness of breath or chest pain.

The patient had a grade III/VI systolic ejection murmur, but the heart rate and rhythm were regular. The lungs were clear. Neurologically, the right leg was weaker than the left, but normal sensation was maintained. Otherwise, the neurologic examination was unremarkable. The abdominal examination was negative except for mild, nonlocalized tenderness.

The ED physician suspected that the patient had had a stroke and ordered appropriate testing. The tests included CT of the head and a carotid artery sonogram. The results of the CT were negative, but the carotid sonogram showed bilateral carotid artery dissection. As a consequence, the physician ordered CT of the chest and abdomen with intravenous contrast enhancement. What do these CT scans show (see Figure 1)?  

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