Aortic saddle embolism and paraplegia due to a large left ventricular thrombus.

A 52-year-old man presented with an acute excruciating back pain and paraplegia with the clammy and pulseless legs, grade 0/5 power, and a sensory level at T10. 8 h later magnetic resonance imaging (MRI) spine showed bilateral psoas muscle infarction with a normal spinal cord. Computed tomography (CT) angiogram showed a thrombotic occlusion of the infra-renal aorta and a large thrombus within the left ventricle [Figure 1]. 12 h later, he developed massive melena and expired. Spinal cord imaging may be normal in up to 14% of patients with spinal infarction in the early phase,[1] although, surrogate markers such as vertebral body infarction on T2-weighted MRI may be present.[2] Nevertheless, acute paraplegia accompanied by severe back and limb pain is highly suggestive of spinal infarction.[3] Saddle aortic embolism and paraplegia from embolism of a left ventricular clot is uncommon.[4] Psoas muscle infarction on MRI has not been described with an aortic thrombo-embolic occlusion.

Figure 1

(a) Axial T2-weighted images showing high signal intensity in both psoas muscles consistent with muscle infarction. (b) Coronal reformatted image shows thrombus filling infra-renal aorta and bilateral iliac arteries. (c) Coronal reformatted post-contrast computed tomography (CT) showing bilateral renal infarcts appearing as wedge shaped non-enhancing areas. (d) Volume rendered images showing complete occlusion of the infra-renal aorta and superior mesenteric artery. (e) Bowel ischemia; dilated fluid filled ileal, and jejunal loops with non-enhancing walls. (f) Post-contrast CT image showing thrombus within the left ventricle