A woman in her early 70’s with altered mental status and left-sided weakness

DJ Wallman, MD

Authors:

Daniel J. Wallman, MD. Department of Internal Medicine. Boston Medical Center.

Patrick Field, MD. Department of Internal Medicine. Boston Medical Center.

Word count: 162 with question teaser, 148 without question teaser.

Corresponding Author Information:

Daniel Wallman, MD.

12 Agassiz Park, Jamaica Plain, MA. 02130

Telephone: 203 981 8338

Email: Daniel.wallman@bmc.org

What treatment options should be considered for the patient with the echocardiogram shown above?

A woman in her early 70s presented with altered mental status and decreased power in her left extremities. Non-contrast computed tomography of the head revealed a sub-acute left cerebellar infarct. Once admitted, a point-of-care echocardiogram showed an echodensity in the atria straddling the interatrial septum suggestive of a paradoxical embolus-in-transit, which was confirmed by standard echocardiography (video 1). Doppler ultrasound revealed bilateral lower extremity deep vein thromboses. Magnetic resonance imaging of her brain revealed acute, bilateral frontal lobe infarcts. Thrombolysis and thrombectomy were avoided given the concern for hemorrhagic transformation of her cerebral infarctions and high surgical risk. She was transferred to the ICU and treated with a heparin infusion. Her clinical status worsened, likely from ongoing venous and arterial emboli, and died 11 days later. With increased availability of ultrasonography, a point-of-care echocardiogram may be warranted for patients with suspected embolic strokes if standard echocardiography is unavailable[1].

[1]       P. Kraft, A. Fleischer, S. Wiedmann, V. Rücker, D. Mackenrodt, C. Morbach, U. Malzahn, C. Kleinschnitz, S. Störk, and P. U. Heuschmann, “Feasibility and diagnostic accuracy of point-of-care handheld echocardiography in acute ischemic stroke patients – a pilot study,” BMC Neurol., vol. 17, no. 1, p. 159, 2017.

Video 1: Paradoxical Embolus-in-transit. An echodense structure can be seen straddling the interartrial septum between the atria.

File title and type: Paradoxical Embolus JAMA 9_14_18 with lables.mov; Paradoxical Embolus 9_14_18 without lables.mov

Figure 1: Paradoxical Embolus-in-transit between Right Atrium and Left atrium.