Abstract
We report a case of cerebrovascular accident with thromboembolic stroke etiology in a patient who had atrial flutter and negative transesophageal echocardiography (TEE) results. The increased D-dimer levels (1877 ng/mL) initiated referral for magnetic resonance imaging and magnetic resonance angiography of the brain that showed classic recanalization of an embolic thrombus in the angular branch of the left middle cerebral distribution. The D-dimer level of this patient was normalized after 3 months of anticoagulation therapy. Although TEE is considered the gold standard for evaluation of cardiac source of embolism, exclusion of intracardiac thrombus with TEE alone does not eliminate the risk of thromboembolic events. This case highlights the utility of D-dimer as a potential adjunct in the decision-making process to guide investigation of thromboembolism, determine subsequent therapy, and hence reduce the risk of embolic stroke recurrence.
Highlights
Despite a decade of intense public education and medical advancement, stroke continues to represent a leading cause of long-term disability and death.[1]
We present an evidence-based case of cerebral embolism when transesophageal echocardiography (TEE) did not show any cardiac source thrombus
A negative TEE obviates the need for prolonged anticoagulation prior to cardioversion, it does not eliminate the presence of intracardiac thrombi that may generate stroke in about 1% of patients.[10,12]
Summary
Despite a decade of intense public education and medical advancement, stroke continues to represent a leading cause of long-term disability and death.[1]. Further investigation for cardioembolic stroke was initiated due to a positive risk marker, the increased plasma D-dimer level. A TEE was performed and showed no evidence of thrombus in the heart including the left atrial appendage (Figure 1B), no valvular vegetations, normal left ventricular function, and a small secondum ASD (Figure 1C).
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