From heart to brain: a Case Report of individualized antithrombotic management for left ventricular thrombus and stroke in a young patient with acute myocardial infarction.

BACKGROUND

Left ventricular thrombus (LVT) is a serious complication of acute myocardial infarction (AMI), conferring a high risk of systemic embolism. The management of LVT becomes exceedingly challenging when complicated by acute ischemic stroke and recent percutaneous coronary intervention (PCI), creating a therapeutic trilemma that lacks guideline-directed recommendations.

CASE SUMMARY: A 27-year-old male with hypertension and diabetes presented with acute anterior ST-segment elevation myocardial infarction. Due to unsuccessful initial revascularization at a local hospital, he underwent delayed PCI on day 10 post-infarction at our center. On the first post-PCI day, he developed acute ischemic stroke, and echocardiography confirmed a mobile left ventricular thrombus as the embolic source. Navigating competing risks of stent thrombosis, hemorrhagic transformation, and recurrent embolism, an individualized six-phase antithrombotic strategy was implemented. This dynamic approach included acute-phase de-escalation, sequential anticoagulation with rivaroxaban followed by warfarin guided by thrombus response, stepwise de-escalation after complete revascularization, and eventual transition to long-term dual-pathway inhibition. Complete LVT resolution was achieved within 6 months, and the patient's neurological deficits fully recovered. No recurrent LVT, ischemic events, or major bleeding occurred during 18 months of follow-up.

CONCLUSION

This case highlights the complex management challenges of left ventricular thrombus and acute stroke following myocardial infarction, and underscores the value of individualized, phased antithrombotic strategies guided by dynamic risk assessment and serial imaging, rather than rigid adherence to single-disease guidelines.