Ischemic Neurologic Event in a Child as a
Result ofVentricular Septal Aneurysm
M. Kowalski, MD, E Hoffman, MD, J. R62afiski, M D , and
W. Rydlewska-Sadowska, M D , FESC, Warsaw, Poland

Aneurysm of the interventricula~ septum without a
shunt was found by means of transthoracic
echoeardiography in a 6-year-old boy with acute
hemiparesis. Until the time of the incident, he had
been healthy. The aneurysmal sac contained 2
clots, p r e s u m a b l y r e s u l t i n g i n t h e i s c h e m i c c e r e b r a l

infarct. On the basis of the echocardiographic
scan, successful surgery was p e r f o r m e d . To the
b e s t o f o u r k n o w l e d g e , t h i s is t h e f i r s t r e p o r t
describing such dramatic sequelae of interventric u l a r s e p t a l a n e u r y s m . (J Am Soc Echocardiogr 1998;
11:116i-2.)

A n e u r y s m s o f t h e v e n t f i c u l a r s e p t u m are m o s t likely c o n g e n i t a l in origin. 1 T h e y m a y b e a n isolated finding o r may o c c u r w i t h o t h e r cardiac malformations.
M e m b r a n o u s a n e u r y s m s t e n d to d e v e l o p as t h e
result of incomplete closure of ventricular septal
defects. 2 Little is k n o w n a b o u t t h e natural history o f
a n e u r y s m s . T h e c o n d i t i o n m a y b e e i t h e r clinically
silent o r associated w i t h a left-to-right shunt, ventricular arrhythmia, endocarditis, ventricnlar outflow
t r a c t obstruction, o r aortic insufficiency. 1-3 Its unusual e m b o l i c p o t e n t i a l has b e e n r e p o r t e d . 1,4
We d e s c r i b e a p e d i a t r i c c a s e in w h i c h t h r o m b u s
f o r m e d inside t h e a n e u r y s m a l sac, resulting in a neurologic ischemic event.To the best of our knowledge, this c o m p l i c a t i o n has n o t b e e n r e p o r t e d previously.

tricuspid valve was suspected. On the basis of this finding,
infective endocarditis or myxoma was considered, and the
boy was referred to the National Institute of Cardiology.
On admission, his condition was inlproved.The electrocardiogram showed a regular sinus rh3qhm with a ventricular
rate of 80 bpm and right bundie branch block.The chest
radiograph was normal. Repeated tmnsthoracic echocardiography disclosed a saccular aneurysm of the ventricular
sepmm withom a shunt (Figures 1 and 2).The aneurysmal
sac contained 2 clots. No other malformation was detected. The clots were suspected as causing the neurologic
event.The boy qualified for surgery and underwent excision of the septal aneurysm and closure of the resultant
ventricular septal defect.Two excised masses were round
shaped and had diameters of approximately 2 cm and 1
cm. Histologically, the wall of the sac was fibrous.The sac
contained tiarombus in the organization stage, without
signs of inflammation.
Postoperative recovery was uneventf~.At 9 months of
follow-up, the boy remains well.

CASE R E P O R T
A 6-year-old boy was admitted to a city hospital because of
an acute complete le•sided hemiparesis. Until that tirne~
he had been healthy. On admission, he was unconscious
with spastic left hemiparesis. On the electrocardiogram,
there was a regular sinus rhythm with a ventricular rate of
100 bpm.The immediate computed tomographic scan was
noncontributory, but the second scan performed 2 weeks
later revealed a low-density area consistent with ischemic
cerebral infarct. An abnormality of the septal leaflet of the

From the Nonmvasive Cardiology Department, National Institute
of Cardiology, Warsaw, Poland.
Reprint requests: Miroslaw Kowalsld, MD, Insrimte of
C~rdiology, Noninvasive Cardiology Department, Alpcjska 42,
04 628 W~rszawa, Poland.
Copyright 9 I998 by the Americ~m Society of Echocardiography.
0894-7317/98 $500 + 0 27/1/93970

DISCUSSION
A h i g h p r e v a l e n c e o f e m b o l i c events has b e e n n o t e d
in individuals w i t h atrial septal aneurysm. 5 Aneurys. ms
o f t h e v e n t r i c u l a r s e p t u m are i n f r e q u e n t . A m o n g
c o m p l i c a t i o n s , an e m b o l i c p h e n o m e n a may occur. 1
In t h e past, it w a s s u g g e s t e d only at autopsy:4 Arora
et al6 r e p o r t e d a case o f a 15-year-old girl w h o h a d
a c u t e left h e m i p a r e s i s a s s o c i a t e d w i t h a t h r o m b u s
f o r m e d inside t h e t r u e left v e n t r i c u l a r a n e u r y s m . W e
h a v e n o t found, h o w e v e r , any r e p o r t c o n c e r n i n g a
n e u r o l o g i c e v e n t that r e s u l t e d f r o m a t h r o m b u s formation within the aneurysm uf the interventricniar
septum. We d e m o n s t r a t e d clots inside an a n e u r y s m
a s s o c i a t e d w i t h c e r e b r a l infarct. V e n t r i c u l a r s e p t a l
1161

Journal of the American Society of Echocaxdiography
December 1998

1162 Kowalski et al

Figure 1 Lm'ge ventricular septal aneurysm (An) bulging
into rigJat intlow tract visualized by moditied 4-chamber
apical view. Two clots are seen inside sac. LA, Left atrium;
/C4, right atrium; LV, left ventricle; RF, right ventricle.

aneurysms should be looked for carefully with
transthoracic echocardiography after an unexplained systemic embolism in children.

REFERENCES
1. Bax0n MG, Wolf BS, Grishman A, Van Mierop LFI.
Ameuxysm of the membranous septum. Am J Roentgenol
1964;91:1303 14.

Figure 2 Parasternal short axis view of 2 dots inside interventricular aneurysm (An). LA, Left atrium; RA, right
atrium; LV, left ventridr RV, right ventricIe.
2. Pombo E, pilapil VR, Lehan PH. Aneurysm of the membra
nous ventricular septum. Am Heart I 1970;79:188-93.
3. GraffignaA, Minzioni G, RessiaL, Vigano M Sar~cai abla
tion of ventricular tadaycardia secondary to congenital ven
tricular septal aneurysm. Ann Thorac Surg 1994;$7:921-4.
4. Guccione F. Aneurismadissectante del setto interventricolare
(pars membranocea). Arch di bin 1926;3:55-67.
5. BelkinRN, Hurwitz BJ, KissloJ. Atrial septal aneurysm:assoclarion with cerebrovascular and peripheral emboIic events.
Stroke 1987;18:856-62.
6. Arora RP-, Issenberg I-II, Spindola-Franco t-I, Fayemi A,
Steeg C. Congenital anettrysmof the left ventricle: its recognition and significance,lAMA 1988;259:3306-8.

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