PMC3362228_01
a, b Brain MRI showing bilateral restricted diffusion and edema in the occipital lobes (right > left) and punctuate foci in the right frontal lobe representing acute infarct. c Brain MRI, axial T1 post-contrast image showing no enhancement in the infarcted area.
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F1
Stroke protocol was initiated and MRI of the brain with contrast showed restricted diffusion and bilateral occipital lobe edema, right greater than left, and punctuate foci in the frontal lobes, left caudate and both cerebellar hemispheres, representing acute embolic infarcts (fig. 1a, b). Non-enhancement in T1 post-contrast image of the brain ruled out the possibility of metastases (fig. 1c).
a TEE showing small (7 x 2 mm) mobile linear echodensity on the aortic side of the right aortic valve cusp, consistent with vegetation. b Repeat TEE after the anticoagulation showing the decrease in the size (2 mm) of the vegetation.
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F2
Given the suspicion of embolic stroke, a transesophageal echocardiogram (TEE) was obtained, which showed a small mobile linear echodensity (fig. 2a) on the aortic side of the right aortic valve cusp, most consistent with vegetation. A repeat TEE done after the initiation of anticoagulation revealed a decrease in the size of the vegetation (fig. 2b).
a, b Abdominal CT showing the metastases to the liver, and T10 vertebral body. c Abdominal CT showing the multiple wedge-shaped infarcts in both kidneys. d Chest CT showing an acute pulmonary embolus in the subsegmental artery of the right lower lung lobe.
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F3
During hospitalization, a CT of the thorax, abdomen and pelvis was done to monitor the progression of OCCC, which showed new metastases to the liver, mesentery and T10 vertebral body (fig. 3a, b). Additionally, an acute pulmonary embolus in the subsegmental arteries of the right lower lung lobe and multiple wedge-shaped infarcts in both kidneys were found (fig. 3c, d).