How do you treat patients with stroke thought to be secondary to Lambl excrescence?

Pathophysiologically, these occur through sheer stress to the valvular endocardium causing small areas to be denuded followed by fibrin deposition and microthrombi formation on the endocardial injury, which can embolize. Histopathologically, they have similarities to fibroelastomas (which are larger and hence more prone to embolization). While there have been case reports and series about using just aspirin, DAPT, and anticoagulation (warfarin (more common) or apixaban), recurrence reported in the antiplatelet group was more common, however, this should be interpreted with caution since in many cases reported (for aspirin single therapy, DAPT or anticoagulation), there were no reports of follow up. In cases with recurrence, surgical excisio...

The definitive treatment is surgical removal. If that is not possible, then I would try anticoagulation, but without much evidence of efficacy.