Case study: unique presentation of cerebral thromboembolism secondary to left ventricular thrombus formation in the setting of Takotsubo cardiomyopathy.

Abstract

Presentation: A 37-year-old female presented with splenic infarcts following a one-week history of abdominal pain and associated nausea and vomiting. Contributing factors included chronic hepatitis C infection and anxiety, exacerbated by recent legal proceedings.

Findings: Echocardiography was performed to exclude cardiac source of thrombo-embolism, demonstrating a 2.9 × 1.3 cm apical left ventricular thrombus and apical left ventricular ballooning suggestive of Takotsubo cardiomyopathy. There were no features to suggest infective endocarditis. Intravenous heparin was commenced. Repeat echocardiography performed several days later demonstrated increased clot mobility and the patient was referred to a tertiary service for consideration of open thrombectomy. On inter-hospital transfer, the patient developed right upper limb weakness, paraesthesias, expressive dysphasia and visual obscuration, which self-resolved after 2 hours. Cerebral imaging following neurological recovery demonstrated multifocal acute infarcts involving the left basal ganglia and parieto-occiptal cortex without haemorrhagic transformation. Coronary angiography was performed and excluded significant coronary artery disease; left ventriculogram was not performed. The patient was commenced on heart failure specific therapy. Serial echocardiography demonstrated return of normal left ventricular systolic function and absence of thrombus.

Conclusion: This is a rare presentation of Takotsubo cardiomyopathy causing formation of a left ventricular thrombus with resultant multi-organ emboli and infarction.