Hyperacute simultaneous cardiocerebral infarction related to floating thrombus in the ascending aorta: a case report

Abstract

Background Ascending aortic thrombus has been reported in several case reports, often revealed by peripheral embolization, but very few revealed by cardiocerebral infarction. Moreover, there is no defined treatment strategy. Case Summary An 83-year-old woman was admitted to our intensive care unit for concurrent acute myocardial infarction (AMI) and acute stroke, both with the presence of an embolism. Imaging revealed a floating thrombus in the ascending aorta. The thrombus resolved after anticoagulant therapy was administered, and there was no subsequent embolism recurrence. Discussion Floating thrombus in the ascending aorta is an unusual cause of AMI. The main mechanisms of thrombus formation include erosion of an atherosclerotic plaque, but it can also form without tissue abnormality with the probable implication of Virchow’s triad. However, the precise mechanism for thrombogenesis remains unknown. In patients with a low surgical risk, we should consider surgical treatment, especially as anticoagulant therapy does not appear to reduce the risk of arterial embolization. Thrombolysis and endovascular interventions have also proven effective in certain cases. Overall, in patients with high surgical risk, decision will have to be made on a case-by-case basis. Learning point Ascending aortic thrombus should be suspected in cases of multiple systemic embolisms. Simultaneous AMI and ischemic stroke should lead to a search for arterial embolization, and it could be useful to perform a head and chest CT scan prior to cardiac catheterization in case of neurologic symptoms in the context of AMI.

Case Report: concurrent myocardial and cerebral infarction due to aortic thrombus

“…The discovery of acute aortic pathology during invasive angiography is suboptimal and can precipitate further embolic events. 2 Astute clinical assessment leading to deferral of emergent invasive angiography was crucial to avoiding such harm in our patient. Alongside bedside echocardiography, ECG-gated CT angiography is clearly the imaging modality of choice for excluding acute aortic syndromes and is recommended by European Society of Cardiology guidelines in the setting of ST-elevation if aortic dissection or pulmonary embolism is suspected.…”

“…Aortic mural thrombus is a rare condition, with an estimated prevalence of 0.45% recorded in a series of over 10 000 autopsies. 3 Simultaneous coronary and cerebral embolization has occasionally been described, 2 , 4 but visceral or limb ischaemia are more typical manifestations. Mural thrombus is associated with underlying aortic atheroma in ∼50% of cases 3 ; other causes include aortic dissection, aortitis, and aneurysm, 5 which were not apparent in this case.…”

A Mobile Thrombus of the Thoracic Aorta

“…In addition, a risk of embolic events following lysis of the thrombus attachment site after the initiation of the treatment was also suggested. 2,3,5,7,12,13 However, none of the studies were randomized. Due to the low prevalence of a mobile thrombus, as well as the need of individualized treatment based on the clinical and radiologic presentation, randomization is almost not feasible.…”