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Now You See It, Now You Don't: Point-of-Care Ultrasound Identification of Left Ventricular Thrombus-in-Transit
Zachary Boivin1, Zhayna Spooner2, Christina Jiang3
1Emergency Medicine Residency.
Insights
Point-of-care ultrasound (POCUS) identified a mobile left ventricular thrombus-in-transit. Serial POCUS revealed thrombus propagation, prompting a change in diagnosis to ischemic stroke and highlighting POCUS
Area of Science:
- Cardiology
- Neurology
- Emergency Medicine
Background:
- Left-sided intracardiac thrombi often result from conditions causing decreased cardiac flow, such as myocardial infarction or atrial fibrillation.
- These thrombi pose a risk of systemic embolization, potentially leading to cerebrovascular accidents.
- Thrombus-in-transit identification via point-of-care ultrasound (POCUS) is critical due to high associated morbidity and mortality.
Purpose of the Study:
- To report a case of left ventricular thrombus-in-transit identified by POCUS in a patient with altered mental status.
- To illustrate the utility of serial POCUS in detecting thrombus propagation and guiding clinical management.
- To emphasize the importance of considering thrombus-in-transit in the differential diagnosis of acute neurological events.
Main Methods:
- A 60-year-old male patient presented with altered mental status and hypotension.
- Cardiac POCUS was performed, revealing a left ventricular thrombus-in-transit.
- Serial POCUS examinations were conducted, alongside neuroimaging and clinical assessment.
Main Results:
- Initial POCUS identified a left ventricular thrombus-in-transit.
- A repeat POCUS <10 minutes later showed the thrombus was absent, with increased vasopressor requirements.
- Subsequent neuroimaging confirmed a large ischemic stroke in the left internal carotid and middle cerebral artery distribution.
Conclusions:
- Serial POCUS examinations are crucial for assessing thrombus propagation and treatment efficacy.
- Identification of thrombus-in-transit necessitates prompt further investigation for underlying critical pathology, such as ischemic stroke.
- This case underscores the value of POCUS in emergency medicine for rapid diagnosis and management changes in critical care scenarios.
Background:
Left-sided intracardiac thrombi are most commonly seen in conditions with decreased cardiac flow, such as myocardial infarction or atrial fibrillation. They can be propagated into the systemic circulation, leading to a cerebrovascular accident. Identification of thrombus-in-transit via point-of-care ultrasound (POCUS) has the potential to change patient management given its association with high patient morbidity and mortality.
Case Report:
An intubated 60-year-old man was transferred to our emergency department for management of altered mental status and seizure-like activity. The patient was markedly hypotensive on arrival, and cardiac POCUS was performed to identify potential causes of hypotension. A left ventricular thrombus-in-transit was identified. The thrombus was notably absent on a repeat POCUS examination < 10 min later, which led to concern for thrombus propagation. Furthermore, the patient's vasopressor requirements had significantly increased in that time period. Subsequent emergent neuroimaging revealed a large ischemic stroke in the left internal carotid and middle cerebral artery distribution. The patient was, unfortunately, deemed to not be a candidate for either thrombectomy or thrombolysis and ultimately expired in the hospital. Why Should an Emergency Physician Be Aware of This? Serial POCUS examinations identified the propagation of this patient's thrombus-in-transit, leading the physician to change the initial presumptive diagnosis and treatment course, and pursue further imaging and workup for ischemic stroke. Identification of a thrombus-in-transit is a clue to potentially underlying critical pathology and should be followed with serial POCUS examinations to assess for treatment efficacy and thrombus propagation.
