Recurrent De Novo Left Ventricular Thrombus During Delayed and Interrupted Anticoagulation for Hemorrhagic Transformation: A Case Report

Background: Left ventricular (LV) aneurysm after myocardial infarction is a recognized source of cardioembolic stroke, and anticoagulation is recommended once LV thrombus is demonstrated. When a large cerebral infarct is complicated by hemorrhagic transformation (HT), however, anticoagulation is often delayed or interrupted. Intracardiac thrombus formation during such intervals is rarely documented on serial imaging. Case Presentation: An 82-year-old man with prior non-ST-elevation myocardial infarction presented with acute ischemic stroke caused by right internal carotid artery (ICA) occlusion. Endovascular thrombectomy (EVT) achieved complete reperfusion, and initial transthoracic echocardiography and chest computed tomography showed an LV apical aneurysm without visible thrombus. Because HT developed after EVT, anticoagulation was withheld and later initiated with warfarin. An LV apical thrombus detected during subtherapeutic anticoagulation was no longer visible on imaging obtained 24 h later, coinciding with recurrent ICA occlusion after the international normalized ratio had reached the therapeutic range. After warfarin was stopped because of progression to parenchymal hematoma, a second de novo thrombus formed in the same aneurysm during the subsequent interruption. Anticoagulation was resumed with warfarin and brief intermediate-dose low-molecular-weight heparin bridging, after which the thrombus regressed without further embolic or hemorrhagic events before transfer. Conclusions: This case suggests that a post-infarction LV apical aneurysm may remain capable of forming thrombus despite preserved global systolic function and initially negative cardiac imaging. When HT necessitates delayed or interrupted anticoagulation, individualized repeat imaging may help detect newly formed LV thrombus in selected patients with a persistent LV aneurysm or regional akinesia.