A 70-year-old man with a history of arterial hypertension, diabetes, hypercholesterolemia, and acute myocardial infarction presented with acute onset right hemiplegia and aphasia. His medications consisted of clopidogrel bisufate, rosuvastatin calcium, atenolol, and perindopril erbumine. Brain magnetic resonance imaging showed an acute left middle cerebral artery infarction on diffusion-weighted imaging (Figure, A). Electrocardiography showed a normal sinusal rhythm, and no significant carotid stenosis was seen on computed tomographic angiography. Treatment with clopidogrel was replaced with aspirin. Two weeks after admission, signs of distal toe ischemia occurred (Figure, B). Skin biopsy confirmed necrosis with occlusion of arterioles in the absence of cholesterol crystals (Figure, C). Ultrasound duplex scanning of the leg showed no arterial stenosis or occlusion. Transesophageal echocardiography revealed large aortic plaques with a thickness of up to 15 mm and multiple mobile thrombi (Figure, D). Intravenous unfractionated heparin sodium treatment was started and substituted with oral anticoagulation 4 weeks later. No other vascular event occurred.
Renard D, Stober N. Cerebral and Peripheral Embolism of Aortic Origin. Arch Neurol. 2007;64(6):894-895. doi:10.1001/archneur.64.6.894