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Valvular Strands: A Rare Cause for Stroke in a Young Patient FREE TO VIEW

Karishma Kitchloo, MD; Pang Lam, MD; Abhinav Saxena, MBBS; Taek Yoon, MD; Chanaka Seneviratne, MD; Yizhak Kupfer, MD
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Maimonides Medical Center, Brooklyn, NY

Chest. 2015;148(4_MeetingAbstracts):268A. doi:10.1378/chest.2281759
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SESSION TITLE: Critical Care Student/Resident Case Report Posters II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Valvular strands, also known as Lambl's excrescences, have been noted to be associated with cerebrovascular events. They are a rare finding, often detected on routine transesophageal echocardiogram (TEE)1.

CASE PRESENTATION: The patient is a 41-year-old male with a past medical history of Rheumatic fever, presenting with sudden onset weakness in his upper and lower extremities, associated with left-sided upper and lower paresthesias and dizziness. The patient received tissue plasminogen activator (tPA) within one hour of presentation, with complete resolution of his neurological deficits, consistent with an aborted stroke. CT head and MRI of the brain were both negative for acute intracranial disease; however, CT angiogram of the head showed a right hypodensity in the right thalamus and posterior capsule, suspicious for an acute ischemic event. Transthoracic echocardiogram (TTE) showed an ejection fraction of 55% with impaired diastolic filling. As TTE was negative for a source of embolus, a TEE was performed and showed a rheumatic mitral valve and a 5-mm mobile soft-tissue mass with a 3-mm valve strand. Patient was then continued on maintenance therapy with low-dose aspirin and clopidogrel.

DISCUSSION: It is estimated that between 14-30% of all strokes are caused by cardioembolic events and up to 40% of strokes have no identifiable cause2. Valvular strands are a rarely documented cause of strokes. As a result, many studies have not been conducted in determining an appropriate treatment regimen - with some studies suggesting antiplatelet therapy versus anticoagulation versus no intervention3. We are uncertain of the mechanism in which tPA resulted in aborting a stroke in our patient. We suggest that in a patient with a history of rheumatic heart disease, evidence of valvular strands on TTE or TEE, and a presentation of a cerebrovascular accident, they be started on either antiplatelet therapy or anticoagulation for primary prevention of recurrent thromboembolic events.

CONCLUSIONS: Valvular strands are often an incidental finding on TEE, which can be considered as a potential risk for cerebrovascular events, and can be treated with appropriate medical management.

Reference #1: Leitman, M., V. Tyomkin, E. Peleg, R. Shmueli, R. Krakover, and Z. Vered. "Clinical Significance and Prevalence of Valvular Strands during Routine Echo Examinations." European Heart Journal - Cardiovascular Imaging 15.11 (2014): 1226-230.

Reference #2: Arboix A, Alió J. Cardioembolic Stroke: Clinical Features, Specific Cardiac Disorders and Prognosis. Current Cardiology Reviews. 2010;6(3):150-161. doi:10.2174/157340310791658730.

Reference #3: Roberts, J. K., I. Omarali, M. R. Di Tullio, R. R. Sciacca, R. L. Sacco, and S. Homma. "Valvular Strands and Cerebral Ischemia : Effect of Demographics and Strand Characteristics." Stroke 28 (1997): 2185-188. Print

DISCLOSURE: The following authors have nothing to disclose: Karishma Kitchloo, Pang Lam, Abhinav Saxena, Taek Yoon, Chanaka Seneviratne, Yizhak Kupfer

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