Cardioembolic stroke secondary to Lambl’s excrescence on the aortic valve: a case report

Abstract

A 59-year-old right-handed man presented to the emergency room with difficulty in understanding simple
commands. There was no historical evidence of any
such focal neurological symptoms or complaints. He
received intravenous tissue plasminogen activator (IVtPA) and showed significant improvement, so he was
transferred to our institution for further management.
The patient had a history of schizophrenia and Parkinsonian symptoms secondary to chronic use of antipsychotics. He was on haloperidol and cogentin daily. He denied
any use of tobacco, alcohol, or recreational drugs. On
physical examination, the patient was afebrile with a
blood pressure of 148/92 and a regular heart rate of 76.
On neurological examination, he was found to be awake
and alert. He had profound difficulty with naming, repetition, reading, and following simple commands. Cranial
nerve examination was unremarkable. Motor examination revealed no focal weakness. Sensory, coordination,
and motor examination were unremarkable.
Laboratory workup revealed normal complete blood
count, basic metabolic panel, and liver function tests.
Magnetic resonance imaging (MRI) of the brain showed
a moderate-sized region of acute infarction in the left
middle cerebral artery (MCA) territory involving a portion of the insula and superior aspect of the temporal
lobe. Magnetic resonance angiographic (MRA) studies
revealed evidence of thrombosis in the left M2 division
of the MCA. A transthoracic echocardiogram (TTE)
revealed an ejection fraction of 70% and no evidence of
thrombus or patent foramen ovale. Further workup
included a transesophageal echocardiogram (TEE)
which showed a linear, 1.1 cm mobile echodensity on
the ventricular surface of the aortic valve leaflets, a finding that is consistent with Lambl’s excrescence (LE)
[Figures 1(A) and (b)]. The patient refused anticoagulation with Coumadin and was therefore started on aspirin
and Lipitor. Cardiothoracic surgery recommended outpatient followup and evaluation for surgical removal of
the Lambl’s excrescence. The patient was discharged to
home in a stable condition. Followup hypercoagulable
workup was unremarkable.