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Stroke is a rare but serious complication of penetrating heart injuries (PHIs). This complication should be suspected in patients with focal neurologic signs.
A 28-year-old man was brought to the emergency department with a single stab wound to the left fourth intercostal space. He had no associated injuries. He was agitated with a blood pressure (BP) of 80/60 mmHg and a heart rate of 130 bpm. The external jugular veins were distended. Cardiac tamponade was highly suspected, rapid fluid resuscitation was initiated, and pericardiocentesis was immediately performed with aspiration of 75 ml of nonclotting blood. The patient was emergently transferred to the operating room where a left posterolateral thoracotomy was done. The effusion was evacuated. A laceration measuring 2 cm in length over the left ventricle was repaired.
Transient episode of asystole has occurred. He responded to internal cardiac massage and intravenous epinephrine, followed by initiation of the massive transfusion. A 32 French chest tube was left in the left pleural cavity and the chest was closed.
Postoperatively, the patient was admitted to the Intensive Care Unit. His BP was stabilized with 1 mg/h of norepinephrine and was extubated on the following day. A bedside transthoracic echocardiography (TTE) was performed on postoperative day 1 with normal left ventricular (LV) size and good ventricular wall function.
The patient was weaned off of vasopressors by postoperative day 2. However, the patient remained somnolent and developed right-sided hemiparesis and a partial visual field loss. Brain computed tomography (CT) scan showed the bilateral occipital and right frontal cortico-subcortical hypodensities [Figure [Figure1a1a and andb].b]. Brain magnetic resonance imaging (MRI) performed shortly after the CT scan revealed the bilateral frontal and right occipital high-signal lesions in fluid-attenuated inversion recovery compatible with recent infarct on the diffusion-weighted imaging B1000 image [Figure [Figure1c1c and andd]d] associated with the presence of microbleeds on T2-weighted image [Figure [Figure1e1e and andf].f]. These imaging findings were suggestive of cardioembolism.
Repeated TTE showed no abnormal findings. Transesophageal echocardiography found neither intracavitary thrombus nor patent foramen ovale. There was only a thin rim of pericardial effusion.
An emergency neurology consultation was called. Given the high suspicion of cardioembolic source of the stroke, it was decided to start careful anticoagulation therapy. The patient was discharged after 2 weeks of hospital stay. At last follow-up, we noted a significant neurofunctional improvement.
We propose through this case presentation to summarize the main causes of heart trauma-related sources of embolism and the current approaches for the diagnosis and management of this complication.
Stroke is a relatively rare but well-documented complication of PHIs. Echocardiography is the cornerstone imaging modality for diagnosis of LV thrombi and other trauma-related sources of embolism. Anticoagulation therapy should be conducted carefully to prevent the first or recurrent stroke after PHIs with close clinical and neuroimaging monitoring.
There are no conflicts of interest.