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

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.