Description

A 61-year-old man presented with sudden onset of left-sided weakness and slurred speech that had started 1 h prior to presentation. He was a non-smoker and his medical history included hypertension and ischaemic heart disease for which he was receiving treatment. On examination he had dysarthria, dense left-sided hemiplegia and upper motor neurone lesion of the facial nerve. His initial brain CT was reported as normal. Since he had presented within the window period for thrombolysis, he was thrombolysed with tPA (tissue plasminogen activator). Post-thrombolysis his neurological status improved considerably. The ECG demonstrated left bundle branch block, while the cardiac enzymes were negative. Subsequently cardiac echocardiography was done which showed dilated left ventricle with an ejection fraction of 20%. The apex, septum, apico-lateral and inferior walls were akinetic. A large friable, mobile thrombus measuring 4.17×1.47 cm (figure 1) was attached to the apex and protruding into the left ventricle (video 1). A diagnosis of left ventricular thrombus secondary to dilated ischaemic cardiopathy was made. Anticoagulation was initiated while he was in hospital. At discharge he was advised to continue warfarin, aspirin, statin and his usual antihypertensive medication.

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Figure 1

Apical four-chamber view of echocardiogram showing left ventricular clot that measured 4.17×1.47 cm in dimension.

The detection of left ventricular clot in cases of embolic stroke carries prognostic and therapeutic importance. Our case demonstrates the classic echocardiographic features of left ventricular clot that increase its propensity for embolisation. These features include the presence of a mobile and protruding thrombus.1 Patients with documented left ventricular clot are recommended to receive oral anticoagulants (with target international normalised ratio of 2.5) for secondary prevention of further thromboembolic episodes.2