A floating mural thrombus in the ascending aorta can cause multiorgan infarction

Abstract

A man in his 50s with sudden-onset left-sided subcostal pain was diagnosed with splenic infarction by thoracoabdominal CT with contrast enhancement, which also revealed a mural thrombus in the thoracoabdominal aorta, raising the possibility of aortic dissection. The electrocardiographic findings were normal and transthoracic echocardiography did not detect thrombus in the heart. Antihypertensive medication was administered on admission, and anticoagulation therapy was started after he developed left renal infarction and occlusion of the superior mesenteric artery. Nevertheless, he subsequently sustained an acute cerebral infarction. Transoesophageal echocardiography revealed an abnormal floating structure in the ascending aorta, which was surgically removed and finally diagnosed as an organising thrombus. Although most of the causes of multiorgan infarction are cardiogenic, floating mural thrombus can also be a cause. Anticoagulation therapy may be necessary for patients with recurring severe embolisms even when aortic dissection has not been completely ruled out.

Keywords: Cardiothoracic surgery; General practice / family medicine; Stroke.

Figure 1

Findings on thoracoabdominal CT with contrast enhancement performed on admission. Thoracoabdominal CT with contrast enhancement revealed a mural thrombus in the ascending aorta (A, arrowhead), multiple low-density areas in the spleen (B, arrowheads), and mural thrombus in the abdominal aorta (C, arrowhead).

Figure 2

Findings on abdominal CT with contrast enhancement performed on day 2. Abdominal CT with contrast enhancement revealed left renal infarction (A, arrowhead) and a contrast defect in the superior mesenteric artery (B, arrow).

Figure 3

Findings on cranial MRI. Diffusion-weighted cranial MRI showing a hyperdense area in the right frontal operculum (arrowhead).

Figure 4

Findings on transoesophageal echocardiography. Transoesophageal echocardiography shows an abnormal floating structure with a diameter of 15 mm in the wall of the ascending aorta (arrow).

Figure 5

Intraoperative findings. (A) An abnormal structure adhering to the ascending aorta. (B) The abnormal structure removed was approximately 15 mm in size.

Figure 6

Histopathological findings of an abnormal structure on the wall of the ascending aorta that was surgically removed (H&E staining, A: ×400, B, C: ×100). Histopathological findings show an organising clot (A) in which fibroblast cells are infiltrating (B, C).