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Cardiovascular Images
April 10, 2019

A Woman in Her Early 70s With Altered Mental Status and Left-Sided Weakness

Author Affiliations
  • 1Department of Internal Medicine, Boston Medical Center, Boston, Massachusetts
JAMA Cardiol. 2019;4(6):594. doi:10.1001/jamacardio.2019.0758

A woman in her early 70s presented with altered mental status and decreased power in her left extremities. Noncontrast computed tomography of the head revealed a subacute left cerebellar infarct. Once admitted, a point-of-care echocardiogram showed an echodensity in the atria straddling the interatrial septum suggestive of a paradoxical embolus-in-transit, which was confirmed by standard echocardiography (Figure, Video). Doppler ultrasonography revealed bilateral lower extremity deep vein thromboses. Magnetic resonance imaging of her brain revealed acute, bilateral frontal lobe infarcts. Thrombolysis and thrombectomy were avoided given the concern for hemorrhagic transformation of her cerebral infarctions and high surgical risk. She was transferred to the intensive care unit and treated with a heparin infusion. Her clinical status worsened, likely from ongoing venous and arterial emboli, and she died 11 days later. With increased availability of ultrasonography, a point-of-care echocardiogram may be warranted for patients with suspected embolic strokes if standard echocardiography is unavailable.1

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