A 74-year-old woman at handed with a stroke.

A 74-year-old woman at handed with a stroke. Transesophageal echocardiography showed evidence of a thrombus attached to the wall of the ascending aorta that was not discovered by the transthoracic approach. The thrombus was no longer not away after treatment with heparin with no intermittent embolic event. To our knowledge, this is the first report of a thrombus attached to the ascending aorta that was no longer not away after treatment with heparin, was discovered by transesophageal echocardiography, and was contemplation to be the source of cerebral embolic event

Transesophageal echocardiography is superior to transthoracic chocardiography in detecting cardiac source of embolism like as left atrial tumors or thrombus, atrial septal deficiency or aneurysm with patent foramen ovale, and mitral valve prolapse in patients with cerebral ischemia or stroke[1-6] Aortic disease with atherosclerotic debris was lately shown by transesophageal echocardiography to be another source of embolism.[1,7-10] To our knowledge, this is the first report of a patient presenting with a shock who had a thrombus in the ascending aorta discovered by transesophageal echocardiography that was no longer instant after treatment with heparin.

Case Report

A 74-year-old woman with history of treated hypertension had the rapid onset of left hemiparesis and slurr words and was admitted to the neurology service for treatment of a attack She had normal blood press and normal results of physical examination make objection for the neurologic examination that showed apraxia, left hemiparesis with three of five motor solidity and a left Babinski. Comput tomographic scan of the head showed right frontal and left occipital areas of hypodensity consistent with nonhemorrhagic infarction. A transthoracic echocardiogram was obtained that showed mild left ventricular hypertrophy with normal left ventricular systolic function and no cardiac source of emboli.

Transesophageal Echocardiography

Transesophageal echocardiography was performed using a 5-MHz transducer and an echograph (Sono 1000 Hewlett Packard Echograph) after sedation with midazolam. The left atrium and left atrial appendage were normal with no evidence of tumor or thrombi. The patient was in normal rhyme and there was no evidence of left atrial spontaneous contrast. Imaging of the ascending aorta showed a large and mobile mass that is triangular in shape and appeared at times to be attached at its tip to the wall of the ascending aorta about 2 cm superior to the flat of the aortic cusps (Fig 1 left) This mass was contemplation to represent a thrombus or a tumor. The valves appeared normal. There was evidence of atheroma involving the ascending aorta, the descending aorta, and left coronary artery.

The patient was started forward a regimen of heparin drip at 1000 U/h and cardiothoracic surgery service was take counsel ed The plan was to excise that mass from the ascending aorta. Since the patient had been receiving heparin for six days, a repeated transesophageal echocardiogram was performed to confirm the air of the mass just prior to cardiac surgery The repeated transesophageal echocardiogram that was six days apart from the previous ordeal showed the mass in the ascending aorta to be no longer at hand (Fig 1B, right). The proof findings were otherwise unchanged. Since the patient had no clinical evidence of embolism add her condition had improved during the six days, it was assumed that lyse of the thrombus had occurr with heparin preventing further thrombosis.

While the patient was receiving heparin she had a positive stool hemoccult example and underwent colonoscopy that showed evidence of a mass in the proximal descending colon that was hemorrhagic; a biopsy specimen showed cancer of the colon The heparin therapy was discontinued ten days after her hospital admission, and four days later, repeated transesophageal echocardiogram showed no resort of thrombus in the ascending aorta; the patient underwent left hemicolectomy, and a biopsy specimen of the liver showed metastatic adenocarcinoma. The patient was referr to the oncology department.

Discussion

Transesophageal echocardiography provides high-resolution imaging of the heart and aorta because of the clog proximity of the esophagus to these constructions The advantage of transesophageal echocardiography across transthoracic echocardiography relates to imaging of posterior fabrics that are difficult to visualize by dint of standard echocardiography such as the posterior regions of the atria, left atrial appendage, atrial septum ascending aorta, descending aorta, and aortic arch. In detecting a cardiac source of embolism in patients with cerebral ischemia or attack transesophageal echocardiography was found to be superior to transthoracic echocardiography.[1-6] Cardiac source of embolism include left atrial thrombus or tumor, left atrial spontaneous contrast "smoke" atrial septal fault atrial septal aneurysm associated with patient foramen ovale, and mitral valve prolapse. newly come reports suggest that aortic disease with intra-aortic atherosclerotic debris can be a potential source of embolism.[1,7-10] This patient, presenting with a affliction had atheroma of the ascending and descending aorta and in addition had a large mobile mass with a small pedicle attached to the wall of the ascending aorta suggestive of a thrombus (Fig 1A, left) that was lay opened only by transesophageal echocardiography with no abnormality to give an inkling of a source of embolism through transthoracic echocardiography. The mass, presum to be a thrombus, was no longer not past nor future on a repeated study six days later (Fig 1B right) while the patient was receiving treatment with heparin. it is assumed that the thrombus lys and the heparin debared further thrombosis. The patient was improving neurologically with no evidence of any recently made known embolic events to suggest breaking of the mass or thrombus.

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