SESSION TITLE: Cardiovascular Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Evaluation of ischemic stroke patients includes a search for cardioembolic sources using transthoracic and/or transesophageal echocardiography which may miss important findings in some patients. Our patient suffered two cardioembolic strokes and had normal transthoracic echocardiograms following each, but demonstrated a left ventricular aneurysm with thrombus on cardiac magnetic resonance imaging (cMRI).
CASE PRESENTATION: A 44 year-old man with a history of hypertension and remote inferolateral myocardial infarction (MI) presented to our institution with symptoms of acute left hemispheric stroke. He had suffered an acute left middle cerebral artery ischemic stroke and was treated with thrombolytic therapy at another institution 9 months earlier. Echocardiography at that time was normal, and he was treated with aspirin, clopidogrel, a statin and anti-hypertensive medications; anticoagulants were not prescribed. He had no new neurologic symptoms prior to the morning of his index admission. In our Emergency Department an acute ischemic stroke was diagnosed. He received t-PA and was admitted to the Neurosurgical ICU. Electrocardiography showed an age-indeterminate inferolateral MI. Transthoracic echocardiography with agitated saline injection demonstrated normal global and regional left ventricular systolic function; normal chamber sizes, valve structure and function; and no evidence of atrial or ventricular trans-septal communication (Figure 1). A cMRI was then performed, revealing a large mobile thrombus within a narrow oraficed left ventricular apical aneurysm (Figure 2). Due to the imaging discrepancy, contrast-enhanced transthoracic echocardiography was then performed, which demonstrated part of the aneurysm and thrombus only in non-standard views. The patient was anti-coagulated with warfarin but was discharged with worsened neurologic deficits.
DISCUSSION: Diagnostic evaluation for an embolic origin of ischemic stroke routinely includes transthoracic and/or transesophageal echocardiography with agitated saline injection to search for trans-septal patencies, valvular abnormalities, and intracavitary thrombi. In our patient with a previous inferolateral MI, echocardiography failed to demonstrate any cardioembolic source following either stroke, while cMRI demonstrated a thombus-containing ventricular aneurysm as the probable source of both emboli. Had this been diagnosed following his first stroke, anticoagulation may have prevented the second.
CONCLUSIONS: This case suggests that standard echocardiography may fail to exclude cardioembolic sources in some individuals with ischemic stroke. In some patients, including those with recurrent stroke or clear evidence of prior MI, additional imaging modalities (e.g., cMRI) should be considered when echocardiography is unremarkable.
Reference #1: “Cardiac Masses and Potential Cardiac ‘Source of Embolus’” Chapter 15 The Practice of Clinical Echocardiography, 4th Ed. Philadelphia: Saunders Elsevier, 2012
DISCLOSURE: The following authors have nothing to disclose: Walter Beard, Cristen Combs, Stephen Geraci
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