70 year old man with sudden onset of hemiparesia

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Doctor's Information

Name : Abbas
Family :Arjmand Shabestari
Affiliation : Radiology Department, Modarres Hospital, SBMU
Academic Degree: Associate Professor of Radiology
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident : Seyed Amir Ebrahimzadeh

Case Section

Cardiovascular

Patient's Information

Gender : Male
Age : 70

Clinical Summary

70 years old man with previous history of congestive heart failure and pace maker placement presented with acute onset of left hemiparesia.

Imaging Findings

In Chest CT scan with contrast, there is a hypodense filling defect in left atrial appendage without extension to left atrium. Pace maker wires are seen in right atrium. Bilateral pleural effusion, cardiomegaly and athelectasis in right middle lobe are also notable. In Head CT without contrast, there is a hypodense area in right parietal lobe and insula(territory of inferior branch of MCA)

Differential Diagnosis

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Final Diagnosis

Cerebral infarct due to emboli from intra cardiac thrombosis.

Discussion (Related Text)

Thrombus within the heart are the most frequent cause of an intracardiac mass and are most common in the LA and LV, where they present a risk of systemic emboli. Intra-atrial thrombi are usually associated with atrial fibrillation, often secondary to rheumatic heart disease. Thrombosis commonly occurs along the posterior wall of the LA or appandage. Clots within the left atrial appendage are difficult to detect on transthoracic echocardiography but are readily identified with transesophageal echo, CT, and MR. . In patients with atrial fibrillation,laminated thrombus may also occur in the left atrium between the pulmonary veins. Left ventricular thrombi are usually secondary to recent infarction or ventricular aneurysm. The differentiation of tumor versus clot is best done with MR using gradient-echo techniques. Clots typically have low signal, whereas tumors have intermediate signal. Clots will not enhance, whereas neoplasms will typically appear as enhancing masses on CT or MR. Embolism is one of the major cause of cerebral infarction and can be cardiogenic or from ICA.

References

1-Brant WE, Helms CA: Fundamentals of Diagnostic Radiology, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007. 2- John R Haga:CT and MRI of the whole body;5th edition.volume 1;chapter 28,page 1154-5.