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A 66-year-old, previously healthy woman presented with an acute onset of weakness on the left side of the body. A computed tomographic scan of the head revealed a small infarction involving the right parietal subcortical region. The results of carotid ultrasonography, magnetic resonance imaging, and tests for a hypercoagulable state failed to reveal a cause for the stroke. A transesophageal echocardiogram (Panel A) showed long, hypermobile, filiform echodensities on the left coronary cusp of the aortic valve — a finding consistent with the presence of giant Lambl's excrescences of the aortic valve (arrow); they were presumed to be the cause of the stroke. The patient had complete neurologic recovery but had another stroke three weeks later, despite adequate anticoagulant therapy. At the time of aortotomy, slender, filamentous masses with two major trunks measuring 2.5 cm in length (Panel B) were excised from the aortic leaflet, and the native valve was left intact. Histologic examination of sections of the specimens showed a densely hyalinized central core lined by bland-looking, endocardial-type spindle cells — findings again consistent with the diagnosis of giant Lambl's excrescences.
Lambl's excrescences appear to be wear-and-tear lesions that originate in the endothelium of the contact margins of a valve, commonly the aortic valve. Excision may be necessary in cases of cryptogenic stroke.
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