A Case of Kommerell's Diverticulum Initially Detected by Transesophageal Echocardiography
A 73-year-old, right-handed woman with a history of hypertension and diabetes was admitted to our emergency department with a suddenly developed aphasia. She initially had difficulty in expression but it resolved a few hours later. On admission, physical and neurological examination showed no abnormality except for the high systolic blood pressure (160 mmHg) and aphasia. Laboratory tests, including autoimmune markers and vasculitis serology, were normal. Electrocardiogram showed normal sinus rhythm with right bundle branch block. Brain magnetic resonance imaging with angiogram showed no evidence of cerebral infarction but bilateral internal carotid artery (ICA) stenosis. Based on the result of negative perfusion study, transient ischemic attack caused by artery-to-artery micro-embolism was highly suspected. So we performed TEE for the evaluation of cardiac source of embolism. TEE showed no definite source of emboli, evidence of shunt or aortic atheroma. During pull back, transverse view at the descending thoracic aorta (DTA) detected non-mobile bulbous echo-free space attached to the posterior aspect of DTA (). Longitudinal view revealed that the space is connected to DTA and the Doppler study showed flow communication () suggesting that the space is outpouching vascular structure. Intimal flap, intimal rupture, spontaneous echo contrast or circumferential dilatation of DTA was not observed. Computed tomography (CT) angiogram showed right sided aortic arch with aberrant LSCA originating from the previously noted echo-free space on TEE (). Four-vessel angiography with aortography revealed mild to moderate stenosis of bilateral ICAs and aberrant LSCA arising from the aortic diverticulum (). The diagnosis was confirmed as Kommerell's diverticulum. But there was no evidence of esophageal or tracheal compression on the CT scan and she didn't complain any symptoms including dysphagia or hoarseness. The patient was discharged with 100 mg of acetylsalicylic acid and 75 mg of clopidogrel daily and been following up without any symptoms.