Lambl’s Excrescences – Taking the Crypto out of Cryptogenic Stroke: A Case Report and Literature Review

Husam M. Salah^1, , David S. Majdalany² and Devon S. Conway³

¹Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan, 22110Elective Program, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA, 44195

²Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA, 44195

³Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic Foundation, Cleveland, OH, USA, 44195

Cite this paper:
Husam M. Salah, David S. Majdalany and Devon S. Conway. Lambl’s Excrescences – Taking the Crypto out of Cryptogenic Stroke: A Case Report and Literature Review. American Journal of Medical Case Reports. 2018; 6(10):214-217. doi: 10.12691/ajmcr-6-10-5

Abstract

Lambl's excrescences (LE) are thin and long filiform projections arising from the line of closure of cardiac valves. Their etiology is not well understood, but they’re thought to result from a wear-and-tear process. They are typically asymptomatic and best detected by transesophageal echocardiogram. Although controversial, some studies suggest an association between LE, ischemic stroke, and headaches. We describe a 56-year-old man who presented with a 3-day history of bilateral blurry vision within the left visual field. One day prior to his visual symptoms, he developed a severe headache that persisted until his presentation to our hospital. On physical examination, visual acuity and fields were intact, but he reported blurriness in the left visual field of both eyes. Brain MRI showed a wedge-shaped area of restricted diffusion along the medial aspect of the right occipital lobe, indicating an ischemic stroke of the visual cortex. Due to the embolic appearance of the stroke, transesophageal echocardiogram was performed and showed a LE on the aortic valve. No other embolic source was identified. In the absence of another explanation for his stroke, LE was considered the most likely source of his embolic stroke. The patient was treated with antiplatelet therapy. In conclusion, this case report highlights LE as a possible cardioembolic source of stroke and discusses its association with headache. We also provide a review of the current literature on LE and the lack of clear guidelines on its management.

Keywords:
Cerebrovascular disease Stroke Embolism Cardiac Cardioembolic stroke Lambl’s Excrescences Headache

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References:

[1]	Aggarwal A, Leavitt BJ. Images in clinical medicine. Giant Lambl's excrescences. The New England journal of medicine. 2003; 349(25): e24.
[2]	Shiber JR, Fontane E, Adewale A. Stroke registry: hemorrhagic vs ischemic strokes. The American journal of emergency medicine. 2010; 28(3): 331-333.
[3]	Chu A, Aung TT, Sahalon H, Choksi V, Feiz H. Lambl's Excrescence Associated with Cryptogenic Stroke: A Case Report and Literature Review. The American journal of case reports. 2015; 16: 876-881.
[4]	Daveron E, Jain N, Kelley GP, et al. Papillary fibroelastoma and Lambl's excrescences: echocardiographic diagnosis and differential diagnosis. Echocardiography (Mount Kisco, NY). 2005; 22(5): 461-463.
[5]	Homma S, Di Tullio MR, Sciacca RR, Sacco RL, Mohr JP. Effect of aspirin and warfarin therapy in stroke patients with valvular strands. Stroke. 2004; 35(6): 1436-1442.
[6]	Roberts JK, Omarali I, Di Tullio MR, Sciacca RR, Sacco RL, Homma S. Valvular strands and cerebral ischemia. Effect of demographics and strand characteristics. Stroke. 1997; 28(11): 2185-2188.
[7]	Roldan CA, Shively BK, Crawford MH. Valve excrescences: prevalence, evolution and risk for cardioembolism. Journal of the American College of Cardiology. 1997; 30(5): 1308-1314.
[8]	Liu RZ, Yu SY, Li Y. Migraine-like headache and ischemic strokes in two patients with Lambl's excrescences. Chinese medical journal. 2012; 125(18): 3346-3348.
[9]	Davogustto G, Fernando RR, Loghin C. Lambl's excrescence, migrainous headaches, and “tiger stripes”: puzzling findings in one patient. Texas Heart Institute journal. 2015; 42(1): 70-72.
[10]	Aziz F, Baciewicz FA. Lambl's Excrescences: Is Surgical Excision Really Necessary? Texas Heart Institute journal. 2008; 35(1): 90.
[11]	Cha SD, Incarvito J, Fernandez J, Chang KS, Maranhao V, Gooch AS. Giant Lambl's excrescences of papillary muscle and aortic valve: echocardiographic, angiographic, and pathologic findings. Clinical cardiology. 1981; 4(1): 51-54.
[12]	Fitzgerald D, Gaffney P, Dervan P, Doyle CT, Horgan J, Nelligan M. Giant Lambl's excrescence presenting as a peripheral embolus. Chest. 1982; 81(4): 516-517.
[13]	Nighoghossian N, Trouillas P, Perinetti M, Barthelet M, Ninet J, Loire R. [Lambl's excrescence: an uncommon cause of cerebral embolism]. Revue neurologique. 1995; 151(10): 583-585.
[14]	Quinson P, de Gevigney G, Boucher F, et al. [Fibrous aortic valve tumor (Lambl's excrescence) trapped in the right coronary artery. Apropos of a case]. Archives des maladies du coeur et des vaisseaux. 1996; 89(11): 1419-1423.
[15]	Voros S, Nanda NC, Thakur AC, Winokur TS, Samal AK. Lambl's Excrescences (Valvular Strands). Echocardiography (Mount Kisco, NY). 1999; 16(4): 399-414.
[16]	Berent R, Hartl P, Rossoll M, Punzengruber C. [Lambl's excrescence as tumorous heart valve mass]. Deutsche medizinische Wochenschrift (1946). 1998; 123(14): 423-426.
[17]	Wolf RC, Spiess J, Huber R. [Lambl's excrescence and cerebral ischemic insult]. Der Nervenarzt. 2006; 77(12): 1492-1494.
[18]	Siles Rubio JR, Ruiz de Castroviejo del Campo J, Tirado Miranda R, Jansen Chaparro S, Pavlovic D. [Transient ischemic attack due to Lambl's excrescence. Report of a case and review of the literature]. Anales de medicina interna (Madrid, Spain: 1984). 2006; 23(4): 181-183.
[19]	Aziz F, Baciewicz FA, Jr. Lambl's excrescences: review and recommendations. Texas Heart Institute journal. 2007; 34(3): 366-368.
[20]	Jaffe W, Figueredo VM. An example of Lambl's excrescences by transesophageal echocardiogram: a commonly misinterpreted lesion. Echocardiography (Mount Kisco, NY). 2007; 24(10): 1086-1089.
[21]	Nakahira J, Sawai T, Katsumata T, Imanaka H, Minami T. Lambl's excrescence on aortic valve detected by transesophageal echocardiography. Anesthesia and analgesia. 2008; 106(6): 1639-1640.
[22]	Kalavakunta JK, Peddi P, Bantu V, Tokala H, Kodenchery M. Lambl's excrescences: a rare cause of stroke. The Journal of heart valve disease. 2010; 19(5): 669-670.
[23]	Mito M, Kiyuna M, Toda T, et al. [A rare case report of incarceration of Lambl's excrescence of aortic valve resulting in myocardial infarction]. Rinsho byori The Japanese journal of clinical pathology. 2012; 60(8): 758-761.
[24]	Morgan JA, Paone G. Resection of Lambl's excrescence on the aortic valve in a patient with rheumatic mitral valve disease and a left atrial thrombus. The heart surgery forum. 2012; 15(4): E215-217.
[25]	Wu TY, Gerber IL, Roxburgh RH. Thrombo-embolic cerebral infarction secondary to giant Lambl's excrescence. Journal of clinical neuroscience: official journal of the Neurosurgical Society of Australasia. 2013; 20(11): 1632-1634.
[26]	Al-Ansari S, Hindori V, Riezebos RK, Yilmaz A. Multiple Lambl's excrescences with subvalvular extension, a rare cause of cryptogenic stroke: treated by port-access cardiac surgery. BMJ case reports. 2013; 2013.
[27]	Yacoub HA, Walsh AL, Pineda CC. Cardioembolic stroke secondary to Lambl's excrescence on the aortic valve: a case report. Journal of vascular and interventional neurology. 2014; 7(3): 23-25.
[28]	Zampi G, Pergolini A, Tinti MD, Alessi C, Sommariva L. Pitfall in Echocardiography: infective endocarditis or valvular strand? Case report. Medical ultrasonography. 2015; 17(2): 256-258.
[29]	Marstrand P, Jensen MB, Ihlemann N. Valvular Excrescences: A Possible Transient Phenomenon. Case reports in cardiology. 2015; 2015: 380765.
[30]	Kamran H, Patel N, Singh G, Pasricha V, Salifu M, McFarlane SI. Lambl's excrescences: A case report and review of the literature. Clinical case reports and reviews. 2016; 2(7): 486-488.
[31]	Ozturk S, Aktemur T, Kalyoncuoglu M, Durmus G, Can M. Case images: Rare source of cardioembolism: transient ischemic attack in a patient with Lambl's excrescence. Turk Kardiyoloji Dernegi arsivi: Turk Kardiyoloji Derneginin yayin organidir. 2016; 44(7): 619.
[32]	Pizzuti A, Parisi F, Mosso L, Cali' Quaglia F, Tomasello A. Acute Myocardial Infarction in a Patient with Two-Vessel Occlusion and a Large Lambl's Excrescence. Case reports in cardiology. 2016; 2016: 8370212.