Abstract 1761: An Uncommon Cause of Stroke in a 41-Year-old Female
A healthy 41-year-old female experienced sudden onset of right hand weakness, right facial droop and garbled speech. The symptoms lasted for several minutes and then resolved spontaneously. Neurologic exam and head CT were unremarkable. Brain magnetic resonance (MR) imaging demonstrated an infarct in the left frontoparietal operculum; head and neck MR angiogram was unremarkable. A trans-thoracic echocardiogram (TTE) was obtained to evaluate for a patent foramen ovale (PFO) as a cause of paradoxical embolus. Although there was no evidence of PFO, the TTE revealed a 7 × 8 mm pedunculated mass attached to the aortic valve. Trans-esophageal echocardiogram (TEE) confirmed the finding of a highly mobile, echo lucent mass most suggestive of a papillary fibroelastoma (PFE). However, valvular vegetation, thrombus and other primary intra-cardiac tumor could not be excluded. A cardiac MR scan was obtained to further characterize the mass. T2-weighted images demonstrated increased signal within the core of the mass, making tumor more likely than infectious vegetation. The mass also more than doubled in signal intensity after intravenous administration of gadolinium confirming the presence of a vascular source and making thrombus unlikely. The results of non-invasive imaging strongly suggested PFE. In the absence of other stroke source, surgical resection was recommended. Histology of the mass demonstrated a typical budding pattern of fibrous and elastic tissue, confirming the diagnosis of PFE. Papillary fibroelastomas are rare, accounting for less than 10% of primary cardiac tumors; however, they are the most common tumor associated with heart valves. Most PFE are asymptomatic and discovered incidentally. However, due to the risk of embolism, surgical resection is recommended for symptomatic or large left-sided tumors. This case illustrates the importance of a broad differential diagnosis when evaluating a common syndrome (ischemic stroke) in an uncommon circumstance (young patient). It also demonstrates the complimentary nature of echocardiography and cardiac MR in confirming the diagnosis of a cardiac mass prior to invasive therapy. As such, multi-modality imaging has become integral in the evaluation and management of cardiovascular disease.