An 80 year old lady with a history of metastatic sigmoid carcinoma presented with expressive dysphasia and unsteady gait 4 days after commencement of adjuvant capecitabine chemotherapy. MRI demonstrated restricted diffusion and T2/FLAIR hyperintensity involving the course of the bilateral corticospinal tracts, the corpus callosum and the middle cerebellar peduncles. Discontinuation of chemotherapy lead to symptom resolution in 2 days; repeat MRI at 2 months demonstrated reversal of the diffusion changes and improvement of the previous T2W/FLAIR hyperintensity. This report describes the first case of capecitabine induced leukoencephalopathy causing restricted diffusion along the corticospinal tracts, which should be differentiated from other entities that involve the corticospinal tracts (i.e. amyotrophic lateral sclerosis (ALS), primary lateral sclerosis (PLS), hypoglycemic coma, etc.).

Carotid mycotic aneurysm is extremely rare and even more unusual when it is associated with a persistent primitive hypoglossal artery. This artery is the second most common of the embryonic carotid-vertebrobasilar anastomoses. It originates from the cervical internal carotid artery and enters the cranium through a widened hypoglossal canal before anastomosing with the basilar artery. We report a case of an elderly man with a rare Salmonella-induced mycotic aneurysm associated with a persistent primitive hypoglossal artery. Surgical resection of the mycotic aneurysm was complicated by a posterior circulation stroke. To the best of our knowledge, there was no previous report of a carotid mycotic aneurysm associated with a persistent primitive hypoglossal artery thus far in the literature. Owing to the high mortality rate of the carotid mycotic aneurysm, it is imperative to be familiar with the vascular and imaging anatomy prior to surgery particularly in the presence of an embryonic carotid-vertebrobasilar anastomosis. In this report, we highlight the imaging characteristics and treatment options for this rare mycotic aneurysm together with a literature review.

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