Carotid webs are abnormal luminal projections at the carotid bulb associated with blood flow stasis, artery dissection, and subsequent complications. Carotid webs are considered to be a rare variant of fibromuscular dysplasia (FMD). Young individuals with symptomatic carotid webs are found to be associated with ischemic stroke. The incidence of the carotid web is low, and it is rarely reported. Only 150 cases of FMD have been reported so far. FMD is a noninflammatory and non-atherosclerotic arteriopathy. The most common arterial beds involved are renal and extracranial carotids. Presentation varies depending on the location of the arterial bed involved and disease severity. Clinical presentations range from minor headaches to severe headaches, resistant hypertension, acute coronary syndrome, transient ischemic attack, and in some cases, stroke. Diagnosis can be made through non-invasive methods, such as computed tomographic angiography, magnetic resonance angiography, or duplex ultrasonography or invasive imaging methods like catheter-based angiography. Treatment of FMD varies with disease presentation and its location. Asymptomatic carotid or vertebral arteries FMD should be monitored clinically and prescribed aspirin 81 mg daily for primary stroke prevention. Endovascular and surgical therapy with stents or coils is reserved for patients with aneurysms. We present a rare and interesting case of a 54-year-old female who presented with acute ischemic stroke in the setting of right carotid artery web, right internal carotid artery (ICA) thrombus with dissection, and possible pseudoaneurysm.

The American Heart Association defines Infective Endocarditis (IE) or bacterial endocarditis as an infection caused by bacteria that enter the bloodstream and settle in the heart lining, heart valve, or blood vessel [1]. IE is considered the fourth most common life-threatening infection syndrome after sepsis, pneumonia, and intra-abdominal abscess. In 2010, IE was associated with 1.58 million disability-adjusted life years, or years of healthy life lost, as a result of death and nonfatal illness and impairment [2,3]. The variability in clinical presentation of IE and the importance of early diagnosis require a diagnostic strategy that is prompt for disease detection and specific for its exclusion across all forms of the disease [2].

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This case presents a rare scenario in which a patient who sustained a gunshot wound to the left side of his chest was saved by his previously undiagnosed medical condition. CASE PRESENTATION: A 28-year-old male with no reported past medical history presented to hospital after sustaining a gunshot wound to his left chest. On arrival, he was alert and oriented with a GCS of 15. He complained of severe left sided chest pain. His EKG (Figure 1) was suggestive of dextrocardia with a right axis deviation and lead I demonstrating inversion of the P wave. Figure 1: The EKG shows lead 1 with a negative P wave axis and negative QRS complex, with AVF showing a positive QRS deflection. Chest x-ray was significant for a large left sided hemopneumothorax, left rib fractures (6/12), and a left sided pulmonary contusion (figure 1). He underwent medical stabilization and chest tube placement which can be seen in (figure 2). A CT of the abdomen (figure 3) showed a left sided liver with grade 3 laceration; he also had a grade 1 left renal laceration with free air above the kidney. His thoracic and abdominal imaging demonstrated evidence of situs inversus totalis. The patient underwent a laparotomy, including a hepatic laceration repair, with placement of a left sided chest tube which drained 400 ml of blood. Despite surgical intervention and having the chest tube for 7 days, the patient had persistent drainage despite broad spectrum antibiotic therapy. He then underwent video-assisted thoracoscopic surgery (VATS) for evacuation of retained hemothorax. The patient recovered and was discharged with rehabilitation. DISCUSSION: Dextrocardia is defined as a cardiac position that is a mirror image of normal position. Situs inversus totalis is when thoracic and abdominal viscera are reversed including dextrocardia. Physical examination is significant for the presence of right-sided heart sounds on auscultation, with the apical impulse located on the right side of the chest. In addition to the physical examination, EKG supports the diagnosis of dextrocardia. EKG will show right axis deviation, an inverted P-wave and QRS complex in lead I, dominant S waves in leads I and V1 to V6, and reversed R wave progression in the precordial leads. CONCLUSIONS: This is the first report of a gunshot wound to the chest saved by undiagnosed condition of situs inversus totalis with dextrocardia. It is astonishing that this patient is alive and recovering due to the rare condition of dextrocardia with situs inversus. Had this patient had standard anatomy, he would have most likely died as the bullet would have directly pierced the heart.

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