Multiple cerebral emboli from caseous necrosis of mitral annulus calcification

Case contributed by Dr Jayanth Keshavamurthy


65 year old female with dizziness, ataxia and difficulty walking.

Patient Data

Age: 65
Gender: Female

Can you spot the difference in the left side of brain in left image?

The CT on our left is 18 months after the right.

Can you see the tiny new fleck of calcium on the left side of brain?

There is another fleck of calcium in right frontal lobe. Which was seen 18 months before also.

Where did this come from?

Incidentally seen is mitral valve annulus calcification. Tortuous descending thoracic aorta. 

A mass described below: possible etiologies include extension of ectopic  calcification from significant mitral annular calcification (MAC), other possibilities include calcified myxoma or other tumor. The mass appears to have a mobile surface component noted.
The left ventricle is normal size with moderate concentric left ventricular hypertrophy; the basal septum appears to have moderate-severe hypertrophy.
Normal global LV function with ejection fraction 60%.
A moderately sized 7mm x6mm calcified, irregular mass with small mobile surface component is seen in the left atrium. It appears attached to either atrial aspect of the calcified mitral annulus or the adjacent atrial septum.
No thrombus is detected in the left atrial appendage.
The mitral leaflets appear mildly thickened with trace mitral regurgitation.
There moderate mitral annular calcification.
There is trace to mild tricuspid regurgitation.
Injection of agitated saline contrast documented no interatrial or intrapulmonary shunt.

Low signal seen in the mitral annulus suggestive of mitral annular calcification. There is a small mass 5 x7 mm arising from the posterior part of the mitral annular calcification on the atrial side and has mild mobility. These findings are correlated with transesophageal echocardiogram findings significant mitral annular calcification with a mobile component was seen on the transesophageal echocardiogram. MRI is not best for evaluation of calcification.
However these findings appear to be consistent with significant mitral annular calcification with a mobile component. There is no evidence of left atrial mass or myxoma. The mitral leaflets appear to be normal.

SSFP Sequences obtained.



Is this embolic or thrombotic stroke?

Technique: Multiplanar, multisequence non contrasted MRI images of the brain were obtained.
FINDINGS: Since the most recent examination there is now multipl supra and infratentorial punctate areas of diffusion restriction consistent with lacunar infarcts.

The cerebellar hemispheres are predominantly involve right more than left with a focal lesion that
appears more chronic in the left middle cerebellar peduncle. Small focal lesions are seen within the left occipital lobe as well as within the left basal ganglia head of the caudate nucleus and very tiny one in the left frontal as well as right frontal orbital frontal gyrus, right basal ganglia and right temporal lobe in the region of the amygdala and anterior temporal pole and right frontal opercular

Old right cerebellar infarct is again identified with gliotic changes of the subjacent white matter appears unchanged.

There is again very extensive focal and confluent hyperintensity within the corona radiata with extension into the centrum semiovale consistent with microvascular ischemic changes with involvement now of the splenium of the corpus callosum but without diffusion restriction..

1. Severe progressive microvascular ischemic changes as seen in patient with chronic hypertension and/or diabetes with extensive infra and supratentorial punctate areas of diffusion restriction most likely representing embolic phenomena. Rule out a central cause.

Case Discussion

The MRI brain showed the embolic strokes.

So a search for central or cardiac source was performed.

Transthoracic echocardiography, transesophageal echocardiography, then finally a cardiac MRI to confirm the source of emboli.

Based on multiple imaging modalities the source of central embolic stroke is caseous necrosis of mitral valve annular calcifications causing multiple embolic strokes.

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Case information

rID: 35002
Published: 3rd Sep 2015
Last edited: 14th Aug 2019
Inclusion in quiz mode: Excluded

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