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A 79 year old woman was admitted for an episode of left facial paralysis and dysarthria which lasted several minutes. Her history included hypertension which was being treated with valsartan.
At admission, no cardiovascular or neurological abnormalities were detected by physical examination, ECG, and carotid ultrasonography, and the only laboratory abnormalities were a fibrinogen concentration of 4.5 g/l (normal < 4 g/l), and a blood creatinine concentration of 112 µmol/l (normal < 100 µmol/l). An emergency brain computed tomographic (CT) scan revealed a right thalamic and a left parietal lacune. Transthoracic echocardiography—complicated by weak echogenicity—detected major mitral insufficiency with mild dilation of the left atrium. Transoesophageal echocardiography revealed discrete left ventricular hypertrophy, voluminous mitral insufficiency as a result of prolapse of the large valve, moderate right atrial dilation, small aortic atheroma, patent foramen ovale with an aneurysm of the interatrial septum, and a 21 × 13 mm thrombus attached to the right atrial side of the septum (panel). Vitamin K antagonist treatment was started. Follow up echocardiography carried out three weeks later showed that the thrombus had shrunk (to 12 × 12 mm). Aspirin (75 mg per day) was added to the anticoagulant regimen and the patient is currently free of neurological symptoms.