A case of caseous calcification of the mitral annulus: A potential source of embolic stroke

Abstract

Mitral annular calcification (MAC) is a common finding especially among the elderly. Caseous calcification of the mitral annulus (CCMA) is a rare variant of MAC, which may be mistaken for an intracardiac tumor or abscess. The clinical significance of CCMA and its potential as a source for cerebral embolism is not known.A 76-year-old woman with an acute ischemic stroke was found to have CCMA on echocardiography apparent as a round mass with a central echolucent area and an echo-dense smooth border, in the periannular position of the mitral valve. She subsequently suffered a second embolic stroke. The central cavity of the CCMA seemed to communicate with the left atrium on echocardiography, suggesting the causal relationship between the second brain attack and the CCMA. She was anticoagulated and has not suffered any further strokes.Previous case reports have suggested that CCMA is a benign condition. This detailed report suggests that CCMA may be a potential source of embolic stroke. (T. Ohara). altered consciousness and quadriplegia. She had a history of controlled hypertension. On admission, her height, weight, and body temperature were 160 cm, 55 kg, and 36.1 • C, respectively. Her blood pressure was 192/96 mm Hg and heart rate 78 beats/min with regular rhythm. The electrocardiogram showed sinus rhythm, without any ST-T wave changes. Magnetic resonance imaging (MRI) of the brain showed new infarct lesions in the left thalamus and the cerebellum. Prompt treatment with intravenous recom-1878-5409/$ -see front matter

Caseous calcification of the mitral annulus associated with stroke: Report of two cases

“…CMR appears to be an excellent imaging modality for the follow-up of CCAM progression, as it allows a good tissue characterization [4]. In the absence of vascular risk factors or widespread atherosclerosis and when a cardiac embolism is strongly suspected based on radiological criteria such as in our second case, CCAM can be considered as the most probable cause of stroke, and surgery is considered as the treatment of choice [5,15,23]. In these cases, stroke could be the consequence of embolization of small calcification, of thrombus from ulceration of the surface, or fistulization of the caseous necrosis in the lumen of left atrium or ventricle [5,23].…”

“…central cavitation on T2 weighted imaging and inversion recovery sequences, and a typical peripheral ring-like enhancement [13,14]. The potential pathogenic role of MAC and CCAM as a source of embolic stroke has been suggested by several authors but remains controversial [15][16][17][18]. For example, in an elderly cohort, Benjamin et al [16] reported that subjects with MAC had a double risk of stroke, after adjustment for main vascular risk factors, while no association was found by Boon et al on a large series of 657 patients with MAC [19].…”

“…There is no consensus on the best therapy, and some authors also suggest anticoagulant therapy, in particular when there is communication between CCAM and systemic circulation [15,24]. This therapeutic option is interesting as it is reported that MAC and CCAM could be associated with atrial fibrillation [5].…”

Caseous Necrosis of the Mitral Valve: Imaging Methods Allow the Diagnosis and Prevent Surgery

“…[6][7][8] The mechanisms for the occurrence of stroke are unclear; it is unknown whether they occur due to their association with atherosclerosis, age and other risk factors related to the patients, or embolization of fragments of the mass. 6 The differential diagnoses include intracardiac tumors, especially atrial myxoma, thrombosis of the coronary sinus, circumflex artery anomalies, and vegetations and abscesses of the mitral annulus.…”

“…8 Even though CNMV is a rare condition, it is important for cardiologists performing imaging tests to be familiar with this diagnosis, in order to avoid confusion with other masses or abscesses, thus preventing unnecessary surgery.…”