An Unusual Source of Cardioembolic Stroke in a Hypertrabeculated Left Ventricle

Introduction/Background:

Patients with cardioembolic strokes suffer greater debility than those with ischemic strokes from other etiologies. Thrombi formed from the left atrial appendage or left ventricle (LV), from a vegetation, or an intracardiac tumor can potentiate the stroke. This case documents the successful diagnosis and conservative management of a left atrial mass in the setting of an ischemic stroke.

Description:

A 73-year-old male with a history of presumed cocaine-induced cardiomyopathy with reduced ejection fraction, chronic lymphocytic leukemia, and chronic hepatitis C was admitted to the intensive care unit with altered mentation requiring emergent intubation. Magnetic resonance imaging of the brain revealed multiple subacute bilateral infarcts suggestive of cardioembolic etiology. A contrast-enhanced transthoracic echocardiogram (TTE) demonstrated a dilated, hypertrabeculated LV with a moderately reduced LV ejection fraction of 32% with a LV apical thrombi and a 25x20 mm left atrial mass attached to the interatrial septum that was suspicious for atrial thrombus versus myxoma. Subsequent transesophageal echocardiography confirmed a large, pedunculated mass attached to the superior aspect of the interatrial septum. Anticoagulation was initiated and continued throughout an extended hospitalization. The patient was lost to follow-up before obtaining additional cardiac testing.

Discussion:

The patient’s clinical status and pre-existing comorbidities made the usual surgical management of the left atrial mass risk prohibitive. A series of three subsequent echocardiograms showed gradual and complete resolution of the left atrial mass after heparin was started, suggesting its etiology as thrombus. This case represents the successful diagnosis and conservative management of a left atrial mass in the setting of an ischemic stroke. Further studies are needed to determine whether conservative management with anticoagulation alone is safe and effective for undifferentiated atrial masses.