Recurrent Left-Sided Stroke: Caseous Mitral Annulus Necrosis Versus Aortic Valve Lambl's Excrescences

Stroke management proves challenging with caseous necrotic mitral valve and aortic valve Lambl's excrescences.

A 68-year-old woman presented with right-sided weakness. Four months prior, she had a left middle cerebral artery cerebrovascular accident and was started on aspirin, clopidogrel, statin, and angiotensin receptor blocker. New left-sided infarcts were identified, without significant carotid disease. Findings on transesophageal echocardiography indicated severe triple-vessel coronary artery disease, mitral caseous necrosis without valvular dysfunction, and Lambl's excrescences. Clopidogrel was switched to apixaban, and a loop recorder was placed. Coronary revascularization was deferred, with plans for surgical management of the Lambl's excrescences.

Recurrent left-sided strokes without significant carotid disease suggest a cryptogenic etiology. Caseous mitral necrosis and Lambl's excrescence are uncommon causes of cardioembolic stroke, but they must be considered. Management is not standardized but typically involves antiplatelets or anticoagulation, and surgical options must also be discussed.