Title : Multiple cerebral infarcts caused by left ventricular thrombus: A multidisciplinary challenge
Abstract:
Introduction: Left ventricular (LV) thrombus accounts for up to 10% of cardioembolic strokes. It is frequently observed in patients with a history of myocardial infarction, particularly those with anterior STEMI, reduced left ventricular ejection fraction (LVEF), non-ischemic cardiomyopathy, or a low TIMI score. Prompt recognition and management of LV thrombus is crucial to preventing systemic embolization and improving patient outcomes.
Case Report: A 50-year-old male presented to the emergency department with confusion, behavioral changes, and vomiting. Due to his disorientation and lack of accompanying family or co-patient, no reliable medical history could be obtained. On examination, he was agitated and disoriented but had no focal neurological signs such as lateralization, facial droop, aphasia, or abnormal reflexes. His plantar reflexes were down-going bilaterally. Other systemic examinations were unremarkable. Initial investigations revealed hyperglycemia, with normal troponin levels and inflammatory markers. His complete blood count and renal function tests were within normal limits. An ECG showed normal sinus rhythm. A non-contrast CT of the brain demonstrated multiple recent non-hemorrhagic infarcts in the right frontal lobe, bilateral thalamus, right occipital lobe, occipitotemporal region, and left cerebellum. The patient was admitted for further stroke evaluation. He was initiated on dual antiplatelet therapy and insulin for glycemic control. Transthoracic echocardiography revealed left ventricular hypertrophy with an ejection fraction of 40%, a mobile thrombus (1.0 x 0.5 cm) at the apex, and hypokinesia in the anterior septal and apical regions. Diastolic dysfunction with impaired relaxation was also noted. Following multidisciplinary discussions between cardiology and neurology, the patient was started on therapeutic anticoagulation and aspirin. Additional treatments included high-dose statin for dyslipidemia management, as well as a beta blocker to optimize cardiac function. The patient’s condition stabilized, though he remained disoriented regarding time, place, and person. Conclusion: Cardioembolic stroke secondary to left ventricular thrombus may present atypically, with confusion and disorientation, even in the absence of clear neurological deficits. This case underscores the importance of a multidisciplinary approach in diagnosing and managing LV thrombus to prevent systemic embolization. The balance between anticoagulation therapy and the risk of hemorrhagic transformation presents a significant clinical challenge, highlighting the need for careful, individualized management in these patients.
Audience Take Away Notes:
- The audience will gain insight into how cardioembolic strokes can present atypically, such as with confusion and disorientation, without the classical neurological signs like facial droop or motor weakness. This highlights the importance of considering a broad differential in patients with altered mental status
- Attendees will understand the significance of left ventricular thrombus as a cause of cardioembolic strokes, particularly in patients with a history of myocardial infarction, reduced LVEF, or non-ischemic cardiomyopathy. This will emphasize the need for thorough cardiac evaluation in stroke patients, especially when no obvious source of embolism is identified initially
- The presentation will highlight the critical role of a multidisciplinary team, particularly collaboration between cardiology and neurology, in the diagnosis and management of complex cases like cardioembolic stroke due to LV thrombus. This approach helps balance the risks of anticoagulation therapy with the need to prevent further embolic events
- This case report can be useful for other faculty in both research and teaching. The report highlights the clinical presentation of cardioembolic strokes due to left ventricular thrombus, which could serve as a learning tool for students and residents. It emphasizes the importance of a multidisciplinary approach in stroke management, which can enhance education in cardiology, neurology, and internal medicine. Moreover, this case provides insights into managing the risks of anticoagulation, which can inspire further research on balancing anticoagulant therapy in patients with embolic strokes
- This case is highlighting the role of echocardiography in detecting LV thrombus early in stroke patients which can streamline diagnostic tools and guide timely intervention, which could improve clinical outcome
- This case report improves the "design" of clinical workflows in diagnosing cardioembolic strokes. By showing the significance of echocardiography and a multidisciplinary team approach, it can refine protocols for stroke management. The case provides new information about the presentation of LV thrombus-related strokes, assisting clinicians in designing better diagnostic and therapeutic strategies to manage such cases effectively
- The audience will learn about the challenges of managing anticoagulation in patients with stroke, especially the risk of hemorrhagic transformation versus the risk of systemic embolization from a ventricular thrombus. This provides a real-world example of clinical decision-making and risk assessment in such cases
- The audience will appreciate the practical, case-based learning approach, allowing them to relate the clinical scenario to their own practice and consider how they would approach similar cases in terms of investigation, management, and decision-making
- The case reinforces the importance of early recognition of potential cardiac sources of embolism and the timely initiation of treatment to prevent recurrent strokes or systemic emboli
