Apical Hypertrophic Cardiomyopathy: A Rare and Hidden Cause of Stroke

Hypertrophic cardiomyopathy (HCM) is an important but under-recognised cause of cardioembolic stroke, due to impaired myocardial contraction, leading to a region of blood stasis and thus associated thrombus formation. Stroke remains the second leading cause of death worldwide, with increasing incidence even among patients without conventional vascular risk factors and those younger in age. Apical hypertrophic cardiomyopathy (ApHCM), characterised by hypertrophy of the left ventricular apex, is associated with a higher risk of stroke than other HCM variants due to apical cavity obliteration, impaired diastolic filling, and the potential formation of apical aneurysms that serve as a nidus for thrombus. We present the case of a 64-year-old man who attended the emergency department following unilateral peripheral vision loss. He was found to be hypertensive, and a brain MRI confirmed an acute occipital infarct. Subsequent cardiac investigations, including ECG, Holter monitoring, and cardiac MRI, revealed T-wave inversion and evidence of apical hypertrophic cardiomyopathy with an associated subtle aneurysm and an apical thrombus. This case highlights the need to consider ApHCM as a potential cause of ischaemic stroke, where it is typically a less common differential diagnosis. Earlier recognition and individualised management regimens, including counselling and timely anticoagulation, are essential in effectively alleviating symptoms and preventing disease progression.