Right Parietal Ischemic Infarct in the Setting of Obstructive Hypertrophic Cardiomyopathy: a Case Report

Case Diagnosis: 54 year old male with aortic stenosis and obstructive hypertrophic cardiomyopathy who presented for left-sided weakness

Case Description or Program Description: The patient is a 54 year old male with a history of aortic stenosis, hypertension, poorly controlled diabetes mellitus, hyperlipidemia, obesity, and obstructive sleep apnea who presented with left sided weakness. In the emergency department, an initial non-contrast CT scan of the head revealed a right parietal ischemic infarct. The patient received tPA and his NIHSS score improved from 8 to 4 thereafter. After the patient was stabilized, the patient was transferred to the rehab floor, where he began to have episodes of dizziness and near syncope. Cardiology was consulted and the patient’s aortic stenosis was deemed severe with underlying obstructive hypertrophic cardiomyopathy. The patient was a candidate for surgical intervention with septal myectomy and aortic valve replacement and further work up for Fabry disease was recommended. Alpha glucosidase levels are pending.

Setting: Bellevue Hospital acute inpatient rehabilitation floor

Assessment/Results: Transthoracic echocardiography revealed ejection fraction of 75% with evidence of left ventricular outflow obstruction. Left ventricle wall thickness was severely increased as well. Clinically, this points to an obstructive cardiomyopathy with aortic stenosis. The patient requires a septal myectomy and aortic valve replacement.

Discussion (relevance): This case demonstrates how underlying cardiomyopathy can predispose patients to cardioembolic sources of stroke. In this patient, he was initially not exhibiting symptoms of cardiomyopathy until he began partaking in therapy on the rehab floor. It was then when his dizziness was provoked, warranting further work up which revealed cardiomyopathy that requires surgical intervention. The patient is also being worked up for late-onset Fabry disease, with a pending alpha glucosidase level.

Conclusions: Underlying hypertrophic cardiomyopathy may predispose patients to cerebrovascular accidents from cardioembolic sources.