Ischemic Stroke as the Presenting Feature of Anterior STEMI Complicated by LV Thrombus and Pseudoaneurysm

BACKGROUND: Delayed presentation of anterior ST-segment elevation myocardial infarction (STEMI) increases the risk of thromboembolic and mechanical complications. CASE SUMMARY: We report a 41-year-old man who presented with transient right upper extremity weakness and dysarthria and was found to have electrocardiographic evidence of an old anterior myocardial infarction. He experienced chest pain 3 days earlier without seeking medical attention. Cardiac catheterization revealed thrombotic lesions involving the left anterior descending artery and diagonal bifurcation. Echocardiography demonstrated moderately reduced left ventricular systolic function with a large apical thrombus. Brain magnetic resonance imaging showed a small acute ischemic infarct. He was managed medically with antithrombotics and heart failure therapy. Eight weeks later, regular follow-up imaging revealed severe left ventricular dysfunction, aneurysmal remodeling, and pseudoaneurysm formation, requiring urgent surgical repair. DISCUSSION: This case highlights the dynamic progression from thromboembolic to mechanical complications following delayed-presentation STEMI and underscores the importance of early recognition, multimodality imaging, and close follow-up. TAKE-HOME MESSAGES: Delayed-presentation anterior STEMI may first manifest as acute ischemic stroke because of left ventricular thrombus. Close follow-up and multimodality imaging are essential to detect late mechanical complications such as left ventricular pseudoaneurysm.