BACKGROUNDIntracardiac blood cysts are thin-walled cysts which are lined by cobble-stone shaped epithelium, fi lled with nonorganised blood. 1 They were fi rst reported by Elsasser in 1844 2 and are mostly congenital in origin. During autopsy, they are found on cardiac valves in approximately 50% of infants under the age of 2 months and are very rarely found after the age of 2 years. 3 Although they are typically asymptomatic, rarely they can cause complications such as valvular dysfunction, left ventricular outfl ow tract obstruction and embolic stroke, for which there are very few documented cases. 4 -6 Transthoracic and trans-oesophageal echocardiography remain useful diagnostic tools in diagnosing this rare condition. We describe the case of an 87-year-old lady who presented with an embolic stroke in whom trans-thoracic and transoesophageal echocardiography enabled us to diagnose the presence of an underlying blood cyst attached to the mitral valve which appeared to have ruptured. CASE PRESENTATIONAn 87-year-old lady was admitted to hospital after waking up with new onset left-sided arm and leg weakness. She denied any chest pain, palpitations or breathlessness.Her past medical history was only remarkable for sensori-neural deafness and previous urinary tract infections. There was no known history of cerebrovascular events or cardiac history and no known family history of cardiac conditions.Physical examination revealed that she was afebrile with a heart rate of 65 beats per min, blood pressure of 120/60 mm Hg and a respiratory rate of 14 breaths per min with oxygen saturations of 98% on air. Upon neurological examination, she had left-sided weakness with power reduced to 2/5 in her left upper limb and 3/5 in her left lower limb. Her sensation was intact and her plantars were both downgoing. She was unable to mobilise. Her cardiovascular examination was normal, with normal jugular venous pressure, no carotid bruits and normal heart sounds with no added sounds. INVESTIGATIONSLaboratory values demonstrated normal blood count, biochemistry, liver function and clotting profi le. Her fasting glucose and lipid profi le were within normal limits. Her C reactive protein was elevated at 59 mg/l. Her urine dipstick was positive for nitrites, leucocytes and protein suggesting she had a urinary tract infection. Admission ECG showed normal sinus rhythm with no ischaemic changes and her chest radiograph showed normal cardiac contours with normal pulmonary vascular markings. CT of the head showed hypo-attenuation of the periventricular white matter compatible with chronic micro-vascular disease. There was a focus of encephalo-malacia involving the right caudate nucleus, anterior to the caudo-thalamic groove, compatible with a subacute infarct. Carotid artery dopplers did not demonstrate any signifi cant stenosis. Her 24 h ECG demonstrated that she remained in sinus rhythm throughout with no arrhythmias.A diagnosis of subacute right middle cerebral artery territory infarct was made and she was initially given aspirin 300 m...

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