A 61-year-old woman with a history of rheumatic valvular heart disease and permanent atrial fibrillation (AF), chronically anticoagulated with rivaroxaban, presented with acute ischemic stroke and bilateral upper-limb ischemia. Neuroimaging revealed an acute infarction in the right middle cerebral artery territory and a subacute infarction in the left posterior cerebral artery territory (). Doppler ultrasound confirmed arterial occlusion in both upper limbs (). Transesophageal echocardiography demonstrated marked left atrial (LA) enlargement, dense spontaneous echocardiographic contrast within the left atrial appendage […]