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Embolic Stroke Due to Sinus of Valsalva Aneurysm Thrombus
CASE-LETTER
Embolic Stroke Due to Sinus of Valsalva Aneurysm Thrombus
S
inus of valsalva aneurysms are rare and a prevalence of 0.09% in the general population is reported by an autopsy study.1 Thrombus formation in the sinus of valsalva aneurysms are a rare complication and could lead to embolic phenomena. Herein, we report a rare case of sinus of valsalva aneurysm with a thrombus inside it that lead to embolic stroke. An 83-year-old man presented with left arm weakness. Cardiovascular examination was unremarkable except for an irregular pulse and electrocardiogram confirmed atrial fibrillation. Brain magnetic resonance imaging showed an acute infarct in the right frontal lobe. Transesophageal echocardiogram demonstrated no intracardiac thrombi. However, sinuses of valsalva aneurysm with a large thrombus was observed (Figure A). Computed tomography scan of the chest showed aneurysmal dilatation of 2 sinuses of the valsalva; the first, involving the left coronary sinus, was 6.2 4.7 cm2 in size and contained a large thrombus, the second aneurysm was 2.1 1.7 cm2 in size and involved the right coronary sinus (Figure B). Thrombus within the sinus of valsalva aneurysm was considered the source of embolic stroke. Considering the large size of the aneurysms, the risk of rupture and the potential for future thromboembolic events, cardiothoracic consultation was obtained. The patient underwent resection of the sinus of valsalva aneurysms and aortic root repair with Medtronic
Freestyle aortic root bioprosthesis. The postoperative course was uneventful and the patient was discharged to home. Sinus of valsalva aneurysms can be either congenital or acquired. Congenital type aneurysms results from weakness of the elastic lamina that is usually seen in patients with Marfan syndrome, Ehlers-Danlos syndrome or other connective tissue disorders. Acquired aneurysms are frequently caused by diseases affecting the aortic wall like infection and connective tissue disease or by trauma.2 The incidence of sinus of valsalva aneurysms has long remained unclear. Nonetheless, incidence in men is 4 times higher than in women, with the right coronary cusp being the most involved.2 Complications of a sinus of valsalva aneurysm are rare and include rupture and thromboembolic events. Patients with an unruptured aneurysm may rarely present with right ventricular outflow tract obstruction, myocardial ischemia due to coronary artery compression or conduction abnormalities.2-4 Rupture of the right and left sinus of valsalva aneurysm may lead to communication between the aorta and right and left ventricular outflow tracts, respectively. Therefore, rupture of a left sinus of valsalva aneurysm is less clinically significant.2 Sinus of valsalva aneurysms are a potential source of thromboembolic events. To our knowledge there are only 3 cases reported of an embolic stroke caused by a sinus of valsalva aneurysm thrombus.5-7 Patients were 2 women and 1 man with ages ranging from 30-49-years old. In 1 case, the thrombus originated from the noncoronary sinus.7 All patients underwent corrective surgery and had uneventful postoperative course.
FIGURE. (A) Transesophageal echocardiographic short-axis view at the aortic valve level demonstrating left (thick white arrow) and right (thin black arrow) thrombus (T) containing sinuses of valsalva aneurysms. (B) Computed tomography angiogram of the chest showing a large thrombus (T) within the left (thick white arrow) and right (thin black arrow) sinuses of valsalva aneurysms.
Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved. www.amjmedsci.com www.ssciweb.org
333
Ruzieh et al
The present case highlights the significance of extracardiac sources of thromboembolic events. *
Mohammed Ruzieh, MD Qaiser Shafiq, MD, MMSc Laura Murphy, MD Mark Bonnell, MD Samer Khouri, MD Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio *E-mail: [email protected]
The authors have no financial or other conflicts of interest to disclose.
REFERENCES 1. Hope J. A Treatise on the Diseases of the Heart and Great Vessels, 3rd ed, Philadelphia: Lea & Blanchard 1839;466–71.
334
2. Weinreich M, Yu PJ, Trost B. Sinus of valsalva aneurysms: review of the literature and an update on management. Clin Cardiol 2015;38: 185–9. 3. Kerber RE, Ridges JD, Kriss JP, et al. Unruptured aneurysm of sinus of Valsalva producing right ventricular outflow obstruction. Am J Cardiol 1975;35: 918–22. 4. Duras PF. Heart block with aneurysm of the aortic sinus. Br Heart J 1944;6: 61–5. 5. Shahrabani RM, Jairaj PS. Unruptured aneurysm of the sinus of Valsalva: a potential source of cerebrovascular embolism. Br Heart J 1993;69: 266–7. 6. Stöllberger C, Seitelberger R, Fenninger C, Prainer C, Slany J. Aneurysm of the left sinus of valsalva. An unusual source of cerebral embolism. Stroke 1996;27:1424–6. 7. Wortham DC, Gorman PD, Hull RW, Vernalis MN, Gaither NS. Unruptured sinus of valsalva aneurysm presenting with embolization. Am Heart J 1993;125:896–8.
THE AMERICAN JOURNAL VOLUME 352
OF THE
MEDICAL SCIENCES
NUMBER 3
September 2016
Embolic Stroke Due to Sinus of Valsalva Aneurysm Thrombus
S
inus of valsalva aneurysms are rare and a prevalence of 0.09% in the general population is reported by an autopsy study.1 Thrombus formation in the sinus of valsalva aneurysms are a rare complication and could lead to embolic phenomena. Herein, we report a rare case of sinus of valsalva aneurysm with a thrombus inside it that lead to embolic stroke. An 83-year-old man presented with left arm weakness. Cardiovascular examination was unremarkable except for an irregular pulse and electrocardiogram confirmed atrial fibrillation. Brain magnetic resonance imaging showed an acute infarct in the right frontal lobe. Transesophageal echocardiogram demonstrated no intracardiac thrombi. However, sinuses of valsalva aneurysm with a large thrombus was observed (Figure A). Computed tomography scan of the chest showed aneurysmal dilatation of 2 sinuses of the valsalva; the first, involving the left coronary sinus, was 6.2 4.7 cm2 in size and contained a large thrombus, the second aneurysm was 2.1 1.7 cm2 in size and involved the right coronary sinus (Figure B). Thrombus within the sinus of valsalva aneurysm was considered the source of embolic stroke. Considering the large size of the aneurysms, the risk of rupture and the potential for future thromboembolic events, cardiothoracic consultation was obtained. The patient underwent resection of the sinus of valsalva aneurysms and aortic root repair with Medtronic
Freestyle aortic root bioprosthesis. The postoperative course was uneventful and the patient was discharged to home. Sinus of valsalva aneurysms can be either congenital or acquired. Congenital type aneurysms results from weakness of the elastic lamina that is usually seen in patients with Marfan syndrome, Ehlers-Danlos syndrome or other connective tissue disorders. Acquired aneurysms are frequently caused by diseases affecting the aortic wall like infection and connective tissue disease or by trauma.2 The incidence of sinus of valsalva aneurysms has long remained unclear. Nonetheless, incidence in men is 4 times higher than in women, with the right coronary cusp being the most involved.2 Complications of a sinus of valsalva aneurysm are rare and include rupture and thromboembolic events. Patients with an unruptured aneurysm may rarely present with right ventricular outflow tract obstruction, myocardial ischemia due to coronary artery compression or conduction abnormalities.2-4 Rupture of the right and left sinus of valsalva aneurysm may lead to communication between the aorta and right and left ventricular outflow tracts, respectively. Therefore, rupture of a left sinus of valsalva aneurysm is less clinically significant.2 Sinus of valsalva aneurysms are a potential source of thromboembolic events. To our knowledge there are only 3 cases reported of an embolic stroke caused by a sinus of valsalva aneurysm thrombus.5-7 Patients were 2 women and 1 man with ages ranging from 30-49-years old. In 1 case, the thrombus originated from the noncoronary sinus.7 All patients underwent corrective surgery and had uneventful postoperative course.
FIGURE. (A) Transesophageal echocardiographic short-axis view at the aortic valve level demonstrating left (thick white arrow) and right (thin black arrow) thrombus (T) containing sinuses of valsalva aneurysms. (B) Computed tomography angiogram of the chest showing a large thrombus (T) within the left (thick white arrow) and right (thin black arrow) sinuses of valsalva aneurysms.
Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved. www.amjmedsci.com www.ssciweb.org
333
Ruzieh et al
The present case highlights the significance of extracardiac sources of thromboembolic events. *
Mohammed Ruzieh, MD Qaiser Shafiq, MD, MMSc Laura Murphy, MD Mark Bonnell, MD Samer Khouri, MD Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio *E-mail: [email protected]
The authors have no financial or other conflicts of interest to disclose.
REFERENCES 1. Hope J. A Treatise on the Diseases of the Heart and Great Vessels, 3rd ed, Philadelphia: Lea & Blanchard 1839;466–71.
334
2. Weinreich M, Yu PJ, Trost B. Sinus of valsalva aneurysms: review of the literature and an update on management. Clin Cardiol 2015;38: 185–9. 3. Kerber RE, Ridges JD, Kriss JP, et al. Unruptured aneurysm of sinus of Valsalva producing right ventricular outflow obstruction. Am J Cardiol 1975;35: 918–22. 4. Duras PF. Heart block with aneurysm of the aortic sinus. Br Heart J 1944;6: 61–5. 5. Shahrabani RM, Jairaj PS. Unruptured aneurysm of the sinus of Valsalva: a potential source of cerebrovascular embolism. Br Heart J 1993;69: 266–7. 6. Stöllberger C, Seitelberger R, Fenninger C, Prainer C, Slany J. Aneurysm of the left sinus of valsalva. An unusual source of cerebral embolism. Stroke 1996;27:1424–6. 7. Wortham DC, Gorman PD, Hull RW, Vernalis MN, Gaither NS. Unruptured sinus of valsalva aneurysm presenting with embolization. Am Heart J 1993;125:896–8.
THE AMERICAN JOURNAL VOLUME 352
OF THE
MEDICAL SCIENCES
NUMBER 3
September 2016