A 62-year-old man is evaluated in the emergency department for a 3-hour history of transient right arm and right leg weakness. His symptoms resolve while in the emergency department. His medical history is otherwise unremarkable, and he takes no medications.

On physical examination, vital signs are normal, and the remainder of the examination is unremarkable. Laboratory studies are notable for an erythrocyte sedimentation rate of 16 mm/h and an LDL cholesterol level of 70 mg/dL (1.81 mmol/L). A 12-lead electrocardiogram is normal. Carotid duplex ultrasound shows no evidence of hemodynamically significant plaque. A CT of the head without contrast demonstrates no evidence of hemorrhage. MRI of the brain reveals a small left internal capsular infarction.

A transesophageal echocardiogram is obtained. Representative mid-esophageal four-chamber images at end-systole (top panel) and end-diastole (bottom panel) are shown. Which of the following is the most likely diagnosis?

1. Bacterial endocarditis
2. Left atrial myxoma
3. Nonbacterial thrombotic endocarditis
4. Papillary fibroelastoma

Based on the patient'ssymptoms and test results, he likely suffered a minor stroke. His MRI shows evidence of a small stroke, and his sensory disturbances are typical post-stroke symptoms. However, none of the provided options (bacterial endocarditis, left atrial myxoma, nonbacterial thrombotic endocarditis, or papillary fibroelastoma) are entirely applicable to his case.

Explanation:

The symptoms presented by the 62-year-old man are most indicative of a minor stroke or transient ischemic attack. As the MRI of the brain reveals a small left internal capsular infarction, it provides evidence of a small stroke. The brief apparent weakness of the right arm and leg suggests that the stroke impacted the left side of his body. The pins and needles sensation he experienced in his left limbs are typical sensory disturbances that can occur after a stroke.

In terms of the provided options, none of them perfectly fit the situation. Bacterial endocarditis, left atrial myxoma, nonbacterial thrombotic endocarditis, and papillary fibroelastoma would more likely cause abnormal findings on an electrocardiogram or reveal hemodynamically significant plaque on a carotid duplex ultrasound. Therefore, while this case presents a minor stroke, none of the options provided are entirely applicable to this specific medical scenario.

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