Ischemic stroke due to a calcified embolus from the mitral annular valve

A 68-year-old woman was admitted with an acute internuclear ophthalmoplegia. The first brain CT (figure, A) was unremarkable. Transesophageal echocardiography (TEE) demonstrated a mobile mass, attached to the posterior mitral valve leaflet (figure, D). The onset of sudden dysphasia prompted CT imaging, revealing a left temporo-parietal stroke and a small calcification in the left sylvian fissure (figure, B and C), compatible with the mitral valve mass on the first TEE. A repeat TEE showed absence of the mass (figure, E). The association between mitral annulus calcification and stroke has been described,^1,2 but this case strongly supports a causal relationship based on sequential in vivo imaging.

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Figure CT imaging

First CT (A) demonstrates an old lacunar unrelated infarction. Second CT (B) shows hyperacute stroke and small calcification in the left sylvian fissure, maintaining its position on the subsequent CT (C). First transesophageal echocardiography (TEE) (D) shows a hyperechoic mass attached to the posterior mitral leaflet, disappearing in second TEE (E).

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