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Mobile Atherosclerotic Aortic Plaque with Multiple Infarctions: Case Report

Abstract

Introduction

One of the most important causes of stroke and peripheral embolization is the presence of atherosclerotic lesions of the aorta which may lead to severe neurological damage as well as multi-organ failure and death. The modality of choice for the diagnosis of these atheroma’s is Transesophageal echocardiography (TEE) although other investigations such as computed tomography, magnetic resonance imaging and intraoperative epiaortic ultrasound remain complementary.

Case Description

A 61-year-old female with a history of DM type II, hypertension, dyslipidemia and porcelain gallbladder diagnosed 1 month prior to her admission but refused surgical treatment presented to the hospital complaining of severe epigastric pain and vomiting. Her home medications included oral hypoglycemic agents, antiplatelet agent, anti-hypertensive medications and a statin. She was investigated using CT abdomen with contrast and was incidentally found to have an acute total left kidney infarction that was confirmed by DMSA scan. Chronic splenic infarcts were also seen. Transthoracic echocardiography was performed and was unremarkable. The patient later developed a left arm tremor so a CT and MRI brain without contrast were done which showed a subacute ischemic insult with advanced atherosclerotic changes seen at the Vertebrobasilar, cavernous, supraclinoid internal cerebral artery as well as the left proximal anterior cerebellar and middle cerebellar arteries. TEE was performed and showed a moderate size complex atherosclerotic plaque with a mobile elongated component at the aortic arch and descending aorta. The patient was offered endovascular treatment but refused. Therefore, the patient was started on anticoagulants and was scheduled for regular follow up.

Discussion

Despite antiplatelet therapy, the risk of stroke and peripheral embolization remains high in such patients. The information provided by TEE includes the composition, mobility, ulceration and the anatomic relationship of the plaque to the origin of the great vessels. Oral anticoagulation therapy may be considered in stroke patients with aortic arch atheroma in order to prevent further recurrent strokes and embolization.

AbdulRahman Samy Ismaiel

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