A large intracardiac thrombus after a massive ischemic stroke

A 87-years-old patient, with ischemic stroke, was transferred to our department for the occurrence at ECG of atrial fibrillation with rapid ventricular rate and ST segment elevation in the anterolateral leads. Brain CT showed a large ischemic area in the territory of the right middle cerebral artery. Two-dimensional transthoracic echocardiography showed apical ballooning of left ventricle, hyperkinesis of the basal segments and severe LV dysfunction with ejection fraction of 25%. These features and inconsistent troponin raise were highly suggestive of Takotsubo or stress-induced-cardiomyopathy (given the patient's frailty, coronary angiography was not performed). On the third day, echocardiography was repeated and it showed an isoechoic mass (20 × 22 mm; area 4.9 cm²) obliterating the apex, compatible with recent-onset thrombotic formation. In the following days, there was a progressive deterioration of the patient's general conditions leading to death by respiratory arrest complicated by electromechanical dissociation.