STJ thrombi are a rare cause of ischemic stroke and have scarcely been reported in literature.

This is a case report.

Case

A 52-year-old man presented with acute encephalopathy. Initial NIHSS 3 for aphasia and sensory loss on right side. Imaging showed multifocal acute infarcts. He was also noted to have transient bluish discoloration of toes as well as elevated troponins and T wave inversions. Blood cultures were positive for Staphylococcus Pseudintermedius in one of three bottles. CTA chest showed an aortic root dilatation. TTE was unrevealing but TEE bared a large thrombus at the STJ extending into the aorta. Hypercoagulable workup was unremarkable.

Anticoagulation was initiated given the STJ thrombus, followed by urgent resection of the mass. Pathology showed a vessel wall fragment with fibrinous exudate and a blood clot composed of fibrin and inflammatory cells. OR cultures were negative although obtained after antibiotic therapy. Patient did not have additional strokes. On discharge, NIHSS 2 for mild aphasia and sensory deficits. This case demonstrates a systemic embolic shower causing ischemic strokes, myocardial injury, and transient blue toe syndrome from an STJ thrombus. The finding of S. pseudintermedius raised concern for possible infectious contribution to thrombus formation.

1. STJ thrombus should be considered in patients with multi-territorial strokes and systemic embolization.
2. TEE is critical for detecting proximal aortic thrombi that may be missed on CTA or TTE.
3. The potential role of S. pseudintermedius in aortic thrombus formation requires further investigation.

To our knowledge, this represents the first reported case of an STJ thrombus causing cerebral and peripheral embolization in the setting of borderline aortic root dilatation and S. pseudintermedius bacteremia.