Abstract
Stroke / Cerebrovascular accident (CVA) is a leading cause of morbidity and mortality in the world. Ischemic stroke accounts for 87% of the cases, 14-30% of which is attributed to cardio-embolic stroke. Lambl’s excrescences (LE) were first described in 1856 by a Bohemian physician- VilemDusanLambl and is considered a rare cause of cardioembolic stroke subtype. LE are branched filiform structures with undulating movements, 1×4-10 mm in size that are usually found on aortic and mitral valves. An atheroma from LE or LE fragments per se may embolize to cerebrovascular arterial territory causing stroke. Multiple isolated cases of stroke associated with LE have been reported in the literature. We hereby report a scoping study of the findings associated with such cases. A total of 27 cases were identified after various scientific databases including PubMed and Google scholar were searched with keywords “lambi’s excrescences, stroke, cerebrovascular accidents”. Data from these cases were tabulated and analyzed. The mean age at presentation was 51 ± 14.2 (± SD) years with 55% of patient younger than 55 years of age. 56% of cases were males. Transesophageal echocardiogram was more effective in detecting LE when compared to transthoracic echocardiogram. LE were most often found on aortic valve and LE related stroke was most often noted in middle cerebral artery territory. Recurrent stroke was reported in 30%. Management of these cases was highly variable and likely derived from individual experience as LE management guidelines are largely lacking. Single and dual antiplatelet therapy, anticoagulation and valvularsurgery were among the various management strategies employed. We recommend dual antiplatelet after the first episode of CVA related to LE and an antiplatelet in combination with anticoagulation after the second CVA attributed to LE. Also it is reasonable to offer valve replacement after second CVA related to LE as the reccurence rate of CVA is high. Due to rarity in LE reporting and its management a shared decision making has to be made depending on the clinical status of the patient.The formation of a worldwide registry for LE using standardized reporting criteria for the diagnosis with or without incident stroke, would help establish guidelines for the diagnosis and management of this rare, yet serious disease with increased risk of morbidity and mortality.
Highlights
Cerebrovascular accident (CVA) is a known cause of significant morbidity and mortality in the United States [1]
The patients were in the age group of 25 to 78 years and the mean age was 51 ± 14.2 years, median age was 53 years and 44% of the cases were younger than 50 years of age and 55.5% of cases were younger than 55 years. 56% of the cases were reported in males and 44% in females
TTE was reported in 14 cases, of which 6 cases (42.85%) reported Lambl’s excrescences (LE) (2 on aortic valve, 4 on mitral valve), 1 case (7.14 %)raised the suspicion for LE and no LE was detected on TTE in 7 cases (50%) all of whom were noted to have LE on transesophageal echocardiography (TEE)
Summary
Cerebrovascular accident (CVA) is a known cause of significant morbidity and mortality in the United States [1]. Ischemic stroke accounts for majority of strokes [2]. Cardio-embolic strokes account for nearly 14-30% of ischemic stroke and are often associated with recurrence and high mortality [3]. Lambl’s excrescences (LE) (Figure 1) though often reported in transesophageal echocardiography of patients who suffered stroke it is not clear if they are bystanders or the cardio-embolic source of such stoke [4]. Multiple isolated case reports of stroke where LE has been attributed as the cause of stroke have been reported. Guidelines regarding management of LE in the setting of stroke are largely lacking. We here undertake the first scoping study of cases of stroke associated with LE reported to understand the clinical profile of these patients, imaging studies and management that were employed, recurrent rates and mortality
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