Open Journal of Thoracic Surgery, 2012, 2, 13-14 Published Online March 2012 ( 13
Four Years of Altering Neurological Symptoms: A Rare
Case of a Massive Left Ventricular Thrombus in the
Absence of Any Symptomatic Cardiac Disease
Payam Akhyari1, Hiroyuki Kamiya1, Artur Lichtenberg1, Axel Haverich2, Malakh L. Shrestha2
1Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany; 2Department
of Cardiovascular Surgery, Duesseldorf University Hospital, Duesseldorf, Germany.
Received December 14th, 2011; revised January 15th, 2012; accepted February 4th, 2012
Cerebral Thrombemboli with left ventricular origin are occasionally seen in p atients with post-infarction left ventricular
aneurysm or dilatative cardiomyopathy of non-ischemic cause. Freedom of medical history of cardiac disease and cor-
responding symptoms may delay the proper diagnosis, particularly in patients with distinct neurological symptoms and
normal findings in electrocardiogram or cerebral MRI. We report on a rare case of long standing neurological symp-
toms and late diagnosis of a left ventricular thrombus without clinical symptoms or medical history of cardiac disease.
The patient underwent a thrombus extraction via left ventricular apical approach. He was discharged from hospital after
an uneventful course in our clinic with remaining mild neurological symptoms that were partially recurrent under
physiotherapy and logopedic therapy in the course of the following two years. An echocardiographical evaluation of
cardiac function and exclusion of a cardiac source of emboli as a first line diagnostic tool may have led to an early di-
agnosis. Therefore, it should be implemented in the routine examination, independent of cardiac history or present car-
diac symptoms.
Keywords: Cardiac Surgery; Left Ventricular Thrombus; Cerebral Thrombembolism; Echocardiography
1. Introduction
Cerebral Thrombemboli with left ventricular origin are
occasionally seen in patients with post-infarction left ven-
tricular aneurysm or dilatative cardiomyopathy of non-
ischemic cause [1,2]. Most of these patients have a his-
tory of angina or heart failure symptoms that is under
medical or surgical treatment including pharmacological
regimen and interventional or surgical therapy. Compli-
cations resulting from cerebral thrombemboli include
transient ischemic attacks (TIA), prolonged ischemic
neurological deficits or a manifest apoplexy [3]. The as-
sociated symptoms vary from regional sensory impair-
ment to complete loss of motor function, requiring im-
mediate initiation of further diagnostic steps and therapy
2. Case Report
A 56 year old male patient was presented to the emer-
gency unit of a community hospital for partial aphasia
and impairment of fine motor movement. He reported
suffering from nonspecific intermittent paraesthesia and
dysesthesia in both forearms and hands, as well as both
lower extremities for about four years. After a neuron-
logical consultation, oral vitamins were prescribed.
However, symptoms remained with altering intensity
for another two years and the patient occasionally visited
his general practitioner for his complaints.
Subsequent hospitalization for neurological workup in
a community clinic brought no significant finding. A
cranial and cervical MRI showed no pathological finding
at that time. Laboratory blood and liquor tests br ought no
sign of a chronic inflammatory process or infection. Af-
ter discharge under oral Vitamin B complex in the fol-
lowing 18 months the patient was sporadically free of
symptoms, but most of the time numbness and paraes-
thesia of right upper extremity were present. At this time,
a thrombembolic pathology as the main underlying cause
of the observed symptoms was not anticipated, likewise
not anticoagulation or platelet inhibition medication was
initiated. About six months prior to admission to our
clinic he experienced right facial paraesthesia and visual
impairment of the right eye, including partial loss of vi-
sion and occurrence of yellow spots. These symptoms
were neglected by the patient, who meanwhile suggested
a psychological cause underlying his complaints. Adding
Copyright © 2012 SciRes. OJTS
Four Years of Altering Neurological Symptoms:
A Rare Case of a Massive Left Ventricular Thrombus in the Absence of any Symptomatic Cardiac Disease
to his symptoms, few weeks later he experienced a pro-
nounced dysmetria and severe loss of spatial orientation.
Finally, diminished cognitive power and word finding
problems brought him to seek for another neurological
Multiple ischemic lesions typical of embolic character
and of different age were detected on a subsequent cra-
nial MRI that led to a cardiac work up. On a transtho-
racic echo a 60 mm long and 10 - 15 mm thick free float-
ing mass was detected within the left ventricular (LV)
chamber with its base attached to the akinetic anterosep-
tal wall (Figure 1). After angiographic exclusion of coro-
nary disease, the patient underwent an open heart surgical
procedure where the LV thrombotic mass was recovered
via a transmural approach from the heart apex under car-
diopulmonary bypass (Figure 2). Hist opat hologi cal evalua-
tion revealed a thrombotic mass with varying stage of
organization and no indication for malignancy.
After an uneventful postoperative course, the patient
was discharged from the clinic on the 10th postoperative
Figure 1. Massive left ventricular (LV) thrombus adherent
to the anteriobasal wall. Echocardiography. LV, left ven-
tricular cavity; *, thrombus.
Figure 2. Macroscopical aspect of the thrombus after sur-
gical removal. Organized and more recent thrombotic as-
pects can be detected.
3. Summary and Conclusions
An intracardiac source of emboli may be in first line
suggested in patients with prediagnosed cardiac disease.
Also patients presenting with severe neurological symp-
toms are prone to a broad diagnostic work up including
cardiac evaluation. However, in patients with minor spo-
radic neurological complaints and no cardiac symptoms,
arriving at the proper diagnosis may be more problem-
Here, we report on a rare case of long term neurologi-
cal symptoms of changing character and localization with
late diagnosis of a free floating left ventricular thrombus.
This case study shows that the absen ce of any symptoms
typical of cardiac disease and a normal ECG finding
might mislead the search for the underlying cause. The
absence of ischemic lesions on the initial cMRI may be
explained by a minimal size and extension of the cerebral
injury at that early time. While earlier diag nostic workup
has been profoundly mislead by this negative finding, the
true cause remained undetected for more than four years.
We conclude that echocardiographical evaluation of car-
diac function and exclusion of a cardiac source of emboli
is an effective and simple way to add important diagnos-
tic data. Therefore, it should be implemented in the rou-
tine examination, independent of cardiac history or pre-
sent cardiac symptoms.
[1] E. Loh, M. S. Sutton, C. C. Wun, J. L. Rouleau, G. C.
Flaker, S. S. Gottlieb, et al., “Ventricular Dysfunction
and the Risk of Stroke after Myocardial Infarction,” New
England Journal of Medicine, Vol. 336, No. 4, 1997, pp.
251-257. doi:10.1056/NEJM199701233360403
[2] J. R. Stratton, J. W. Nema nic, K. A. Johannessen and J. D.
Resnick, “Fate of Left Ventricular Thrombi in Patients
with Remote Myocardial Infarction or Idiopathic Car-
diomyopathy,” Circulation, Vol. 78, No. 6, 1988, pp. 1388-
1393. doi:10.1161/01.CIR.78.6.1388
[3] G. W. Albers, L. R. Caplan, J. D. Easton, P. B. Fayad, J.
P. Mohr, J. L. Saver and D. G. Sherman, “Transient
Ischemic Attack—Proposal for a New Definition,” New
England Journal of Medicine, Vol. 347, No. 21, 2002, pp.
1713-1716. doi:10.1056/NEJMsb020987
[4] S. C. Johnston, “Clinical Practice. Transient Ischemic
Attack,” New England Journal of Medicine, Vol. 347, No.
21, 2002, pp. 1687-1692. doi:10.1056/NEJMcp020891
[5] H. P. Adams Jr., B. H. Bendixen, L. J. Kappelle, J. Bille r,
B. B. Love, D. L. Gordon and E. E. Marsh III, “Classifi-
cation of Subtype of Acute Ischemic Stroke. Definitions
for Use in a Multicenter Clinical Trial. TOAST. Trial of
Org 10172 in Acute Stroke Treatment,” Stroke, Vol. 24,
No. 1, 1993, pp. 35-41. doi.10.1161/01.STR.24.1.35
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