Functional recovery and thrombus resolution in a young patient with multiple strokes

Introduction: Ischemic stroke in younger adults is not, the underlying factors are more diverse, approximately 15% occurs in adult aged 18-50 years. The TOAST classification is helping tool to differentiate the etiology; many younger patients fall under cardio-embolism. Left ventricular thrombus (LVT) is a complication in non-ischemic cardiomyopathies, the incidence to be as high 36%. LVT were more likely to have a decreased of left ventricular ejection fraction < 50%. The protrusion and mobility of thrombus is a high risk for embolic strokes. Description: A 34 years old male with known arterial hypertension, presented at the hospital with left labial commissure deviation, dysarthria and tetraparesis for less 24 hours, National Institutes of Health Stroke Scale (NIHSS) was 22, blood pressure was 240/120mmHg and urgent computed tomography did not reveal any ischemic lesions, he was treated with esmolol and after the resolution of hypertensive emergency our patient received thrombolytic therapy with alteplase. He was admitted at ICU, the ECG showed sinus rhythm without signs of acute myocardial ischemia, a cardiac POCUS detected global hypokinesia with decreased left ventricular ejection fraction, structurally normal valves and LVT (4cm x 2.8cm) invading the apex, clinically NIHSS 4 points and Glasgow coma scale (GCS) 14 points.The patient recieved enoxaparin 1mg/kg SC and 24 hours after the thrombolysis had a neurological deterioration with Broca aphasia and GCS 10 points with bilateral plantar reflex an MRI was performed showed acute ischemic injury in left parietal lobe and hemorrhagic transformation in right basal ganglia. In the following days, an cardioresonance was performed, showing systolic dysfunction with EF 13%, left ventricle dilatation and eccentric hypertrophy, myocardial infarction with necrosis in the middle-basal inferolateral walls without evidence of LVT. Neurologically with significant improvement patient was discharged 10 days after admission without neurologic sequelae. Discussion: Multiple strokes are rare in young adults, nowadays the use of ultrasonography in the ICU is essential tool, provides rapid bedside diagnosis when used by adequately professionals. It is necessary to continue with the educational programs for the use of the POCUS.