Thrombus in transit in a patient with ischaemic stroke

Stroke or cerebrovascular accident is common and is most commonly embolic or haemorrhagic. A common source of embolism is the heart and as such echocardiogram is an essential investigation. However, clinicians need to be aware of rare sources of embolism. We report a rare and interesting case of a 61-year-old Caucasian man who presented with stroke and on evaluation was found to have a large thrombus coiled striding over a patent foreman ovale into the right and left atrium consistent with a 'thrombus in transit'. The origin of the thrombus was later confirmed to be from the left saphenous vein. This case highlights an interesting case of 'thrombus in transit'.

Incidental finding on computed tomography angiogram

(Refer to page 50) Answer: Anomalous coronary artery Panel (a) shows the right coronary artery traveling between the aorta (posterior) and pulmonary artery (anterior).

An important incidental ECG findings - Answers

(Refer to page 48) Answer: Brugada syndrome The patient did not have any cardiac symptoms or any cardiac enzyme changes suggestive of an acute myocardial infarction (AMI). Although not always present, the finding of reciprocal ST segment depression in opposing leads favours myocardial infarction. This was also not present in the patient’s ECG. Echocardiogram did not show any regional wall motion changes that could be seen in patients with myocardial infarction. Thus the probability of this patient having AMI based on the ECG alone is very unlikely.

An important incidental ECG findings

A 34-year-old male with diabetes mellitus presented with diabetic ketoacidosis. He was treated with insulin. Echocardiography and cardiac enzymes (CKMB and troponin I) were normal. Routine electrocardiogram (ECG) was done and is shown in the above panel. Q: What is the ECG diagnosis? What are the possible diagnoses you would consider? 1: Acute ST segment elevation myocardial infarction (STEMI) 2: Hyperkalemia 3: Brugada Syndrome 4: Normal ST-T changes in a young person Answer: refer to page 69

Incidental finding on computed tomography angiogram

A 42-year-old male presented with a history of presyncope. There was no postural hypotension or neurological cause for syncope. Electrocardiogram (ECG) only showed non-specific ST-T changes in inferior leads. Echocardiogram, exercise stress test and 24 hours holter monitoring were all normal. Computed tomography (CT) angio was done and are shown in the panels above. Q: What is the diagnosis? Answer: refer to page 71