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A complex atheroma of the aortic arch puts a patient at risk for an embolic stroke. We present a patient with no cardiac history who came with acute stroke-like symptoms from a large, complex aortic atheroma. Case presentation: A 60-yearold woman with known thoracic aortic aneurysm presented with acute right-sided weakness. An MRI of the brain showed a left middle cerebral artery (MCA) embolic stroke. A CT angiogram (CTA) showed the known, stable thoracic aneurysm and concern for type A aortic dissection. Later gated CT scan revealed a focal filling defect in the proximal aortic arch, compatible with a floating thrombus. A transesophageal echocardiogram (TEE) then demonstrated a 18mm by 14mm, highly mobile atheroma in this area. Specialty team concluded that the stroke was due to the atheroma and suggested anticoagulation and statin therapy. Discussion: A large and mobile aortic atheromas are recognized as a potential cause of embolic events in the elderly population. These patients will benefit from an anticoagulation and statin therapy to reduce the risk of stroke recurrence. Conclusion: A complex aortic atheroma is likely an independent risk factor for embolic stroke and may be an indication for prophylactic anticoagulation and statin therapy.

Large highly mobile complex ascending aortic atheroma causing left middle cerebral artery stroke in patient without any history of cardiac disease.