Histology of Thrombectomy Specimen Reveals Cardiac Tumor Embolus in Cryptogenic Young Stroke

Mechanical thrombectomy for cerebral embolism due to cardiac papillary fibroelastoma: A case report

Background

Papillary fibroelastoma (PFE) and myxoma are relatively common types of benign cardiac tumors. PFE and myxoma can be associated with fatal embolic events. However, PFE is not widely recognized within the field of cerebrovascular diseases.

Case Description

A 54-year-old male presented with a sudden onset of left hemiparesis. Three-dimensional computed tomography (CT) angiography revealed incomplete occlusion of the right middle cerebral artery. Thrombolytic therapy with recombinant tissue-type plasminogen activator was performed, followed by mechanical thrombectomy. Reperfusion was achieved within 199 minutes, resulting in thrombolysis in cerebral infarction grade 2b. The retrieved emboli appeared as a white gelatinous substance, which was diagnosed as PFE by histopathological examination. Transesophageal echocardiography and cardiac CT identified a 6-mm mobile mass in the left atrium. PFE in the left atrium was considered to be the source of the embolism and tumor resection was performed on day 18. Histopathological findings of the resected tumor were identical to those of the emboli. The patient was transferred to a rehabilitation facility on day 36, with a modified Rankin Scale score of 2.

Conclusion

PFE and myxoma share many clinical features, but PFE tends to be smaller, so detection is more challenging and has likely resulted in under-recognition. PFE and myxoma can be associated with fatal embolic events. Resection is recommended for left-sided, mobile, symptomatic tumors larger than 10 mm. The differential diagnosis of embolus retrieved through mechanical thrombectomy should consider both myxoma and PFE and persistent efforts should be made to detect the embolic origin.

Histopathological findings of endovascular thrombectomy-retrieved specimen reveal cardiac papillary fibroelastoma as the cause of ischaemic stroke

This case reports a rare proximal left middle cerebral artery occlusion caused by cardiac papillary fibroelastoma (CPF), successfully treated with endovascular thrombectomy (EVT) followed by surgical resection of the cardiac tumour. Histological analysis of the EVT-retrieved specimen matched the mass identified on transoesophageal echocardiogram, confirming the diagnosis of CPF-associated embolic stroke. Early identification of CPF through histopathology likely expedited definitive treatment for this patient, who eventually made a full functional recovery.

Clot Composition Analysis as a Diagnostic Tool to Gain Insight into Ischemic Stroke Etiology: A Systematic Review

Mechanical thrombectomy renders the occluding clot available for analysis. Insights into thrombus composition could help establish the stroke cause. We aimed to investigate the value of clot composition analysis as a complementary diagnostic tool in determining the etiology of large vessel occlusion (LVO) ischemic strokes (International Prospective Register of Systematic Reviews [PROSPERO] registration # CRD42020199436). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we ran searches on Medline (using the PubMed interface) and Web of Science for studies reporting analyses of thrombi retrieved from LVO stroke patients subjected to mechanical thrombectomy (January 1, 2006 to September 21, 2020). The PubMed search was updated weekly up to February 22, 2021. Reference lists of included studies and relevant reviews were hand-searched. From 1,714 identified studies, 134 eligible studies (97 cohort studies, 31 case reports, and six case series) were included in the qualitative synthesis. Physical, histopathological, biological, and microbiological analyses provided information about the gross appearance, mechanical properties, structure, and composition of the thrombi. There were non-unanimous associations of thrombus size, structure, and composition (mainly proportions of fibrin and blood formed elements) with the Trial of Org 10172 in Acute Stroke Treatment (TOAST) etiology and underlying pathologies, and similarities between cryptogenic thrombi and those of known TOAST etiology. Individual thrombus analysis contributed to the diagnosis, mainly in atypical cases. Although cohort studies report an abundance of quantitative rates of main thrombus components, a definite clot signature for accurate diagnosis of stroke etiology is still lacking. Nevertheless, the qualitative examination of the embolus remains an invaluable tool for diagnosing individual cases, particularly regarding atypical stroke causes.

Mechanical Thrombectomy for Acute Middle Cerebral Artery Occlusion Caused by Tumor Embolism: A Case Report

Objective

We report a case of acute middle cerebral artery (MCA) occlusion caused by tumor embolism.

Case Presentation

A 64-year-old man with lung cancer presented with sudden onset left-sided hemiparesis and sensory disturbance. Diffusion-weighted imaging (DWI) revealed hyper-intense foci in the right MCA territory and magnetic resonance angiography (MRA) demonstrated right MCA M2 segment occlusion. Mechanical thrombectomy (MT) was performed with Thrombolysis in Cerebral Infarction 2B recanalization. On histopathology, thrombus composed of fibrin and squamous cell carcinoma was observed. We diagnosed him with tumor embolism from lung cancer that invaded the pulmonary vein and the left atrium.

Conclusion

Tumor cells may be confirmed by pathological examination regardless of the morphology of the embolus. Pathological examination of the cerebral embolus is useful for the accurate diagnosis of ischemic stroke subtypes.

Successful endovascular removal of a chondroblastic osteosarcoma embolus within the left middle cerebral artery

A 57-year-old woman with metastatic chondroblastic osteosarcoma developed sudden-onset right-sided weakness and aphasia. She was found to have an occluded left middle cerebral artery (M1 segment) and underwent endovascular stroke intervention with return to a normal neurological exam within 24 h. Histologic analysis of the embolus was consistent with chondroblastic osteosarcoma.

Syncope in a female patient. Echocardiography and cardiac computed tomography reveal an unexpected diagnosis

Papillary fibroelastoma is a benign cardiac tumor with a high potential of embolization. Coronary computed tomography is a valuable tool for the work-up of patients with papillary fibroelastoma, providing accurate information regarding the coronary circulation and morphology of the cardiac mass.