Left ventricular thrombus diagnosed by point-of-care ultrasonography

Now You See It, Now You Don't: Point-of-Care Ultrasound Identification of Left Ventricular Thrombus-in-Transit

BACKGROUND

Left-sided intracardiac thrombi are most commonly seen in conditions with decreased cardiac flow, such as myocardial infarction or atrial fibrillation. They can be propagated into the systemic circulation, leading to a cerebrovascular accident. Identification of thrombus-in-transit via point-of-care ultrasound (POCUS) has the potential to change patient management given its association with high patient morbidity and mortality.

CASE REPORT

An intubated 60-year-old man was transferred to our emergency department for management of altered mental status and seizure-like activity. The patient was markedly hypotensive on arrival, and cardiac POCUS was performed to identify potential causes of hypotension. A left ventricular thrombus-in-transit was identified. The thrombus was notably absent on a repeat POCUS examination < 10 min later, which led to concern for thrombus propagation. Furthermore, the patient's vasopressor requirements had significantly increased in that time period. Subsequent emergent neuroimaging revealed a large ischemic stroke in the left internal carotid and middle cerebral artery distribution. The patient was, unfortunately, deemed to not be a candidate for either thrombectomy or thrombolysis and ultimately expired in the hospital. Why Should an Emergency Physician Be Aware of This? Serial POCUS examinations identified the propagation of this patient's thrombus-in-transit, leading the physician to change the initial presumptive diagnosis and treatment course, and pursue further imaging and workup for ischemic stroke. Identification of a thrombus-in-transit is a clue to potentially underlying critical pathology and should be followed with serial POCUS examinations to assess for treatment efficacy and thrombus propagation.

Use of point-of-care ultrasound to diagnose an alternate cause of flank pain in a patient with presumed renal colic

This is a case of a 34-year-old male patient who presented to the emergency department (ED) with severe left flank pain. Due to the patient's cardiac history, elevated troponin, lactic acidosis, and lack of renal calculi on a noncontrast CT, focused cardiac ultrasound was performed, which showed left ventricle thrombus. The patient was later found to have bi-interventricular thrombi causing both pulmonary embolism and renal infarction. This is an uncommon diagnosis in the ED, where point-of-care ultrasound helped in diagnosing and guiding the management and disposition of this case.