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Abou-El-Hassan H, Azhar Y, Ikram A, Kulik T, Torbey MT. A Large Lambl's Excrescence Causing Embolic Stroke in a Young Patient: A Case Report and Review of Literature. Neurohospitalist 2024; 14:339-346. [PMID: 38895016 PMCID: PMC11181975 DOI: 10.1177/19418744241240523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
Lambl's excrescences (LEs) are thin, filiform and hypermobile strands that develop at the valvular coaptation sites of the heart. Since first described in 1856 by Vilém Dušan Lambl, there has been an increasing number of reports of central and peripheral emboli arising from cardiac LEs. LEs have been linked to ischemic strokes irrespective of age and comorbidities. We report one of the youngest reported cases in literature of an embolic stroke in a 25-year-old woman caused by a LE. A comprehensive workup was performed that revealed a large aortic valve LE. The patient was discharged on dual anti-platelet therapy with outpatient cardiology follow-up for surveillance echocardiograms. We then surveyed the literature and reviewed case reports and observational studies of LEs linked to systemic emboli. We found that most LEs are present on left-sided high-pressure valves especially the ventricular aspect of the aortic valves and that most reported cases of cerebral embolism had aortic valve LEs. The management of cardioembolic stroke secondary to LEs remains unclear. LEs have not been identified as a definite etiology of cardioembolic strokes warranting the need for large-scale studies to help guide the management of cardiac LEs in the setting of ischemic stroke.
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Affiliation(s)
| | - Yusra Azhar
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Asad Ikram
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Tobias Kulik
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Michel T. Torbey
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
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Kariyanna PT, Jayarangaiah A, Rednam C, Hegde S, Marmur JD, Kamran H, Wengrofsky P, Green J, Ahmed R, McFarlane SI. Lambl's Excrescences and Stroke: A Scoping Study. INTERNATIONAL JOURNAL OF CLINICAL RESEARCH & TRIALS 2018; 3:127. [PMID: 30627689 PMCID: PMC6322692 DOI: 10.15344/2456-8007/2018/127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Stroke / Cerebrovascular accident (CVA) is a leading cause of morbidity and mortality in the world. Ischemic stroke accounts for 87% of the cases, 14-30% of which is attributed to cardio-embolic stroke. Lambl's excrescences (LE) were first described in 1856 by a Bohemian physician- VilemDusanLambl and is considered a rare cause of cardioembolic stroke subtype. LE are branched filiform structures with undulating movements, 1×4-10 mm in size that are usually found on aortic and mitral valves. An atheroma from LE or LE fragments per se may embolize to cerebrovascular arterial territory causing stroke. Multiple isolated cases of stroke associated with LE have been reported in the literature. We hereby report a scoping study of the findings associated with such cases. A total of 27 cases were identified after various scientific databases including PubMed and Google scholar were searched with keywords "lambi's excrescences, stroke, cerebrovascular accidents". Data from these cases were tabulated and analyzed. The mean age at presentation was 51 ± 14.2 (± SD) years with 55% of patient younger than 55 years of age. 56% of cases were males. Transesophageal echocardiogram was more effective in detecting LE when compared to transthoracic echocardiogram. LE were most often found on aortic valve and LE related stroke was most often noted in middle cerebral artery territory. Recurrent stroke was reported in 30%. Management of these cases was highly variable and likely derived from individual experience as LE management guidelines are largely lacking. Single and dual antiplatelet therapy, anticoagulation and valvularsurgery were among the various management strategies employed. We recommend dual antiplatelet after the first episode of CVA related to LE and an antiplatelet in combination with anticoagulation after the second CVA attributed to LE. Also it is reasonable to offer valve replacement after second CVA related to LE as the reccurence rate of CVA is high. Due to rarity in LE reporting and its management a shared decision making has to be made depending on the clinical status of the patient. The formation of a worldwide registry for LE using standardized reporting criteria for the diagnosis with or without incident stroke, would help establish guidelines for the diagnosis and management of this rare, yet serious disease with increased risk of morbidity and mortality.
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Affiliation(s)
- Pramod Theetha Kariyanna
- Divisions of Cardiovascular Disease, and Endocrinology, Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, 11203, USA
| | - Apoorva Jayarangaiah
- Department of Internal Medicine, Wake Forest University, Baptist Health System, Winston-Salem, North Carolina, 27157, USA
| | - Chandra Rednam
- Division of Cardiology, Department of Internal Medicine, Veterans Affairs New York Harbor Healthcare System-Brooklyn, Brooklyn, New York, 11209, USA
| | - Sudhanva Hegde
- Divisions of Cardiovascular Disease, and Endocrinology, Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, 11203, USA
| | - Jonathan D. Marmur
- Divisions of Cardiovascular Disease, and Endocrinology, Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, 11203, USA
| | - Haroon Kamran
- Divisions of Cardiovascular Disease, and Endocrinology, Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, 11203, USA
| | - Perry Wengrofsky
- Divisions of Cardiovascular Disease, and Endocrinology, Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, 11203, USA
| | - Jason Green
- Divisions of Cardiovascular Disease, and Endocrinology, Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, 11203, USA
| | - Rodaina Ahmed
- Divisions of Cardiovascular Disease, and Endocrinology, Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, 11203, USA
| | - Samy I. McFarlane
- Divisions of Cardiovascular Disease, and Endocrinology, Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, 11203, USA,Corresponding Author: Prof. Samy I. McFarlane, Divisions of Cardiovascular Disease, and Endocrinology, Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York,11203, USA, Tel: 718- 270-6707, Fax: 718-270-4488;
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Matsukuma S, Koga A, Takeo H, Kato K, Mori K, Sato K. Non-exophytic Lambl excrescences of aortic valves: a morphological study. Histopathology 2016; 69:307-14. [PMID: 26825675 DOI: 10.1111/his.12938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 01/25/2016] [Indexed: 11/30/2022]
Abstract
AIMS To elucidate the histopathological findings of classical Lambl excrescences (LEs) and non-exophytic LEs (non-ex LEs) without excrescent papillary features. METHODS AND RESULTS We examined 126 aortic valves (AVs) and revealed LEs (non-ex and/or classical), non-ex LEs and classical LEs in 106, 78 and 88 AVs, respectively. The detection of non-ex LEs was challenging, but elastica van Gieson stain highlighted their presence. Non-ex and classical LEs chiefly involved the ventricular regions, favoured posterior cusps and coexisted in the same areas of 31 AVs. A possible transformation of classical LEs into non-ex LEs was suggested histologically in 39 AVs. Non-ex LEs were associated with age of >70 years (P < 0.001) and marked deformity (P = 0.007). Classical LEs were associated inversely with marked deformity (P < 0.001), but not with age of >70 years. Compared with age- and sex-matched control AVs, non-ex LEs and marked deformity in dysfunctional AVs were more common (P = 0.037 and P < 0.001, respectively), but classical LEs were less common (P = 0.021). CONCLUSIONS Non-ex LEs have subtle features but are a common form of LEs, and seem to develop from classical LEs. AV dysfunction-related marked deformity can promote non-ex LEs.
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Affiliation(s)
- Susumu Matsukuma
- Department of Pathology, Japan Self-Defense Forces Central Hospital, Tokyo, Japan.,Health Care Center, Japan Self-Defense Forces Central Hospital, Tokyo, Japan
| | - Ayano Koga
- Department of Pathology, Japan Self-Defense Forces Central Hospital, Tokyo, Japan
| | - Hiroaki Takeo
- Department of Pathology, Japan Self-Defense Forces Central Hospital, Tokyo, Japan
| | - Kimi Kato
- Department of Pathology, Japan Self-Defense Forces Central Hospital, Tokyo, Japan
| | - Kazuma Mori
- Department of Pathology, Japan Self-Defense Forces Central Hospital, Tokyo, Japan
| | - Kimiya Sato
- Department of Pathology, Japan Self-Defense Forces Central Hospital, Tokyo, Japan
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Chu A, Aung TT, Sahalon H, Choksi V, Feiz H. Lambl's Excrescence Associated with Cryptogenic Stroke: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:876-81. [PMID: 26655393 PMCID: PMC4684139 DOI: 10.12659/ajcr.895456] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 08/30/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND In 1856, a Bohemian physician, Vilém Dušan Lambl, first described the presence of filiform lesions in aortic valve leaflets. Lambl's excrescences are tiny filiform strands that arise on the line of valve closure, and result from valvular wear and tear. It is a rare cause of cardioembolic stroke that can be detected by transesophageal echocardiogram. CASE REPORT We encountered a 51-year-old, African-American woman with a history of recurrent strokes that we suspect may be the result of Lambl's excrescence. The patient was treated with dual antiplatelet therapy and was recommended to have surveillance transesophageal echocardiograms at 6 months and 1 year from the time of discharge. CONCLUSIONS As there are no definitive guidelines for the management of patients with Lambl's excrescences, we present a review of the current medical literature and a specific case report in an attempt to provide a better strategy for managing this condition. In our case report, we focus on the management and treatment for Lambl's excrescence because no clear evidence has been published in the literature. Our review indicates that Lambl's excrescence, despite its relative scarcity, should be considered in the differential diagnosis of a patient with cryptogenic stroke.
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Affiliation(s)
- Andrew Chu
- Corresponding Author: Andrew Chu, e-mail:
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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. Heart Surg Forum 2013; 15:E215-7. [PMID: 22917827 DOI: 10.1532/hsf98.20121023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Lambl's excrescences (LEs) are filiform strands that form on heart valves and are associated with an increased risk of stroke due to embolization. Although resection of these strands is generally recommended in patients who present with a stroke and no other identifiable cause, the management of incidentally discovered LEs in patients without an adverse cardioembolic event is less clear. We report a case of a patient with severe mitral valve stenosis from rheumatic heart disease and a large left atrial thrombus who was incidentally found to have multiple LEs on her aortic valve. In addition to replacing her mitral valve and removing the left atrial thrombi, we resected the LEs from her aortic valve due to their potential to cause a stroke and the relatively low associated morbidity in resecting them while keeping the aortic valve leaflets and valve function intact.
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Affiliation(s)
- Jeffrey A Morgan
- Division of Cardiothoracic Surgery, Heart and Vascular Institute, Henry Ford Health System, Detroit, MI, USA.
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