Lambl’s excresence (LE) is a rare cause of cardioembolic stroke, most often noted in middle cerebral artery territory. We present two cases of cardioembolic strokes secondary to LE seen on transesophageal echocardiogram (TEE)

Case reports and review of literature

Case 1: 63-year-old man with a history of migraines  was admitted for large ischemic strokes in the right cerebellum manifested by sudden onset vertigo. Head, neck CT angiogram and transthoracic echo (TTE) were unremarkable.  TEE showed small, mobile structure on the arotic valve on the left ventricle side of the left coronary cusp consistent with LE. He was discharged home with outpatient physical therapy, on aspirin 325mg and clopidogrel 75mg daily.

Case 2: 51-year-old man with a history of hypertension and old left middle cerebral artery infarct 5 years ago with previous negative stroke work-up, admitted for two acute ischemic strokes in the head of the right caudate and posterior limb of the right internal capsule manifested by dysarthria, left hemiparesis and left hemisensory deficits. Head, neck CT angiogram and TTE were unremarkable and TEE revealed Lambl's excrescence on the left ventricular aspect of the right coronary cusp. Patient was discharged to rehab on aspirin 81mg and apixaban 5mg twice daily.

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TEE is superior to TTE in detection of LE. There are no definitive guidelines for its management. Literature suggest dual antiplatelet after the first episode of stroke and an antiplatelet plus anticoagulation after the second stroke attributed to LE. Literature also recommends offering valve replacement after second stroke related to LE as the recurrence rate is high.