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Esmaeili S, Shojaei SF, Bahadori M, Mojtahed M, Mehrpour M. Intravenous Thrombolysis for Acute Ischemic Stroke Due to Cardiac Myxoma. Basic Clin Neurosci 2020; 11:855-859. [PMID: 33850622 PMCID: PMC8019853 DOI: 10.32598/bcn.11.6.1844.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/20/2019] [Accepted: 02/10/2020] [Indexed: 11/21/2022] Open
Abstract
Background: Myxoma may cause systemic embolization and frequently presents as ischemic stroke. Case Presentation: There have been debates about whether it is safe to use recombinant tissue plasminogen activator (rt-PA) in patients with cardiac myxoma who referred with ischemic stroke to the hospital’s emergency. Results: The patient was a young case of atrial myxoma with initial presentation of acute cerebral infarction symptoms who was treated with intravenous rt-PA with no complications. Conclusion: The case provides an evidence of the efficacy and safety of intravenous rt-PA in cases of cardiac myxoma. However, we cannot always expect thrombolytic therapy to be effective, especially in tumor emboli.
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Affiliation(s)
- Sara Esmaeili
- Department of Neurology, Cellular and Molecular Research Center, Firoozgar Hospital, Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
| | - Seyedeh Fahimeh Shojaei
- Firoozgar Clinical Research and Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Bahadori
- Department of Neurology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mojtahed
- Department of Neurology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Masoud Mehrpour
- Department of Neurology, School of Medicine, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
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2
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Stefanou MI, Rath D, Stadler V, Richter H, Hennersdorf F, Lausberg HF, Lescan M, Greulich S, Poli S, Gawaz MP, Ziemann U, Mengel AM. Cardiac Myxoma and Cerebrovascular Events: A Retrospective Cohort Study. Front Neurol 2018; 9:823. [PMID: 30337904 PMCID: PMC6178925 DOI: 10.3389/fneur.2018.00823] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 09/11/2018] [Indexed: 12/12/2022] Open
Abstract
Background: Cardiac myxoma (CM) is the most frequent, cardiac benign tumor and is associated with enhanced risk for cerebrovascular events (CVE). Although surgical CM excision is the only curative treatment to prevent CVE recurrence, in recent reports conservative treatment with antiplatelet or anticoagulant agents in high-risk patients with CM-related CVE has been discussed. Methods: Case records at the University Hospital of Tübingen between 2005 and 2017 were screened to identify patients with CM-related CVE. Clinical features, brain and cardiac imaging findings, histological reports, applied treatments and long-term neurological outcomes were assessed. Results: 52 patients with CM were identified and among them, 13 patients with transient ischemic attack, ischemic stroke or retinal ischemia were included to the (to our knowledge) largest reported retrospective study of CM-related CVE. In all identified patients, CVE was the first manifestation of CM; 61% suffered ischemic stroke, 23% transient ischemic attack and 15% retinal ischemia. In 46% of the patients, CVE occurred under antiplatelet or anticoagulation treatment, while 23% of the patients developed recurrent CVE under bridging-antithrombotic-therapy prior to CM surgical excision. Prolonged time interval between CVE and CM-surgery was significantly associated with CVE recurrence (p = 0.021). One patient underwent i.v. thrombolysis, followed by thrombectomy, with good post-interventional outcome and no signs of hemorrhagic transformation. Discussion: Our results suggest that antiplatelet or anticoagulation treatment is no alternative to cardiac surgery in patients presenting with CM-related CVE. We found significantly prolonged time-intervals between CVE and CM surgery in patients with recurrent CVE. Therefore, we suggest that the waiting- or bridging-interval with antithrombotic therapy until curative CM excision should be kept as short as possible. Based on our data and review of the literature, we suggest that in patients with CM-related CVE, i.v. thrombolysis and/or endovascular interventions may present safe and efficacious acute treatments.
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Affiliation(s)
- Maria-Ioanna Stefanou
- Department of Neurology and Stroke, and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Dominik Rath
- Department of Cardiology, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Vera Stadler
- Department of Neurology and Stroke, and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Hardy Richter
- Department of Neurology and Stroke, and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Henning F Lausberg
- Department of Thoracic and Cardiovascular Surgery, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Simon Greulich
- Department of Cardiology, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology and Stroke, and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Meinrad P Gawaz
- Department of Cardiology, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology and Stroke, and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Annerose M Mengel
- Department of Neurology and Stroke, and Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
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3
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Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL, Smith EE. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke 2016; 47:581-641. [DOI: 10.1161/str.0000000000000086] [Citation(s) in RCA: 442] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose—
To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.
Methods—
Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
Results—
After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.
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4
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Ryu B, Ishikawa T, Sato S, Yokote A, Nakamoto H, Nie M, Okada Y. Mechanical Endovascular Recanalization in a Patient with Middle Cerebral Artery Occlusion by Tumorous Emboli Originating from Cardiac Myxoma. NMC Case Rep J 2015; 2:53-56. [PMID: 28663964 PMCID: PMC5364909 DOI: 10.2176/nmccrj.2014-0359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/17/2014] [Indexed: 11/24/2022] Open
Abstract
Cardiac tumor is a rare cause of cerebral embolic infarction which has no established therapeutic strategies. Although some cases were successfully treated by recombinant tissue-plasminogen activator (rt-PA), this article indicates the effectiveness of emergency mechanical thrombectomy for tumorous type of emboli which do not respond to rt-PA. A 34-year-old man presented with ischemic stroke and right middle cerebral artery (MCA) occlusion by cardiac tumor originating emboli. Intravenous rt-PA therapy was ineffective, but mechanical endovascular thrombectomy using Merci Retriever was successful. His neurological deficit began to improve and good outcome was obtained at discharge. The embolus was histologically identical to a cardiac myxoma, confirmed and treated successfully by surgery later. We report the first successfully treated tumorous embolic stroke case with cardiac tumor by using Merci Retriever. Emergency mechanical thrombectomy would be an option for elastic hard myxoma emboli.
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Affiliation(s)
- Bikei Ryu
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo.,Department of Neurosurgery, Ebina General Hospital, Ebina, Kanagawa
| | - Tatsuya Ishikawa
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo
| | - Shinsuke Sato
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo
| | - Akiyoshi Yokote
- Department of Neurosurgery, Ebina General Hospital, Ebina, Kanagawa
| | | | - Masaki Nie
- Department of Cardiovascular Surgery, Ebina General Hospital, Ebina, Kanagawa
| | - Yoshikazu Okada
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo
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5
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Ryu B, Ishikawa T, Sato S, Yokote A, Nakamoto H, Nie M, Okada Y. Mechanical Endovascular Recanalization in a Patient with Middle Cerebral Artery Occlusion by Tumorous Emboli Originating from Cardiac Myxoma. NMC Case Rep J 2015. [DOI: 10.2176/nmccrj.cr.2014-0359] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Bikei Ryu
- Department of Neurosurgery, Ebina General Hospital
- Department of Neurosurgery, Tokyo Women’s Medical University
| | | | - Shinsuke Sato
- Department of Neurosurgery, Tokyo Women’s Medical University
| | | | | | - Masaki Nie
- Department of Cardiovascular Surgery, Ebina General Hospital
| | - Yoshikazu Okada
- Department of Neurosurgery, Tokyo Women’s Medical University
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Kulkarni GB, Yadav R, Mustare V, Modi S. Intravenous thrombolysis in a patient with left atrial myxoma with acute ischemic stroke. Ann Indian Acad Neurol 2014; 17:455-8. [PMID: 25506173 PMCID: PMC4251025 DOI: 10.4103/0972-2327.144038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 05/08/2014] [Accepted: 05/14/2014] [Indexed: 11/26/2022] Open
Abstract
Intravenous thrombolysis (IVT) is an accepted therapy in patients with acute ischemic stroke presenting within 3-4.5 hours of symptom onset. Selection of the patient for thrombolysis depends on the careful assessment for the risk of post thrombolysis symptomatic haemorrhage (6.2-8.9%) which may be fatal. Atrial myxomas which are the commonest tumors of the heart are associated with stroke due to tumor/clot embolism. There are very few case reports of IVT and its outcome in patients with atrial myxoma with stroke. Some have reported successful thrombolysis, while others have reported intracerebral bleeding. In this report we describe our experience of IVT in atrial myxoma patient with ischemic stroke and review the relevant literature.
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Affiliation(s)
- Girish Baburao Kulkarni
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Ravi Yadav
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Veerendrakumar Mustare
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Sailesh Modi
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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van den Wijngaard I, Wermer M, van Walderveen M, Wiendels N, Peeters-Scholte C, Lycklama À Nijeholt G. Intra-arterial treatment in a child with embolic stroke due to atrial myxoma. Interv Neuroradiol 2014; 20:345-51. [PMID: 24976098 DOI: 10.15274/inr-2014-10026] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 01/01/2014] [Indexed: 11/12/2022] Open
Abstract
Arterial ischaemic stroke is an important cause of morbidity in children. Timely diagnosis is necessary for acute stroke treatment but can be challenging in clinical practice. Due to a paucity of data there are no specific recommendations regarding the use of mechanical thrombectomy devices in current paediatric stroke guidelines. A 14-year-old boy presented with a severe acute left hemisphere stroke due to a proximal middle cerebral artery occlusion caused by emboli from an atrial myxoma. No clinical improvement was seen after administration of intravenous thrombolysis. Subsequent mechanical thrombectomy with a second-generation stent-based thrombectomy device resulted in successful recanalization and clinical improvement. To our knowledge, this is the first report of mechanical thrombectomy in a child with acute embolic stroke caused by atrial myxoma.
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Affiliation(s)
- Ido van den Wijngaard
- Department of Radiology, Medical Center Haaglanden; The Hague, The Netherlands - Department of Neurology, Leiden University Medical Center; Leiden, The Netherlands -
| | - Marieke Wermer
- Department of Neurology, Leiden University Medical Center; Leiden, The Netherlands
| | | | - Natalie Wiendels
- Department of Neurology, Leiden University Medical Center; Leiden, The Netherlands
| | - Cacha Peeters-Scholte
- Department of Paediatric Neurology, Leiden University Medical Center; Leiden, The Netherlands
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8
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Kamiya Y, Ichikawa H, Mizuma K, Itaya K, Shimizu Y, Kawamura M. A case of acute ischemic stroke due to cardiac myxoma treated by intravenous thrombolysis and endovascular therapy. Rinsho Shinkeigaku 2014; 54:502-6. [PMID: 24990835 DOI: 10.5692/clinicalneurol.54.502] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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9
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Roeltgen D, Kidwell CS. Neurologic complications of cardiac tumors. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:209-22. [PMID: 24365298 DOI: 10.1016/b978-0-7020-4086-3.00015-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cardiac tumors are an uncommon cause for neurologic disease, but if undiagnosed can be associated with devastating neurologic consequences. Primary cardiac tumors, both benign and neoplastic, and metastatic tumors occur. Primary cardiac tumors are more likely to be associated with neurologic embolic complications. Metastatic cardiac tumors are more likely to be associated with valvular distraction, arrhythmia, diminished cardiac output and indirect neurological dysfunction. Primary and metastatic cardiac tumors may result in cerebral metastatic disease. Atrial myxoma, a benign primary cardiac tumor, is the most common cardiac tumor associated with neurologic disease, and most commonly causes cerebral embolization and stroke. The use of thrombolytic therapy for these strokes is controversial. Additionally, delayed manifestations, including aneurysm formation and intracranial hemorrhage, are possible. Aneurysm formation has been described as occurring after removal of the primary tumor. The availability of noninvasive cardiac imaging has significantly helped decrease the neurologic morbidity of cardiac tumors and has led to frequent successful intervention.
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Affiliation(s)
- David Roeltgen
- Cape Physicians Associates, Cape May Court House, NJ, USA.
| | - Chelsea S Kidwell
- Department of Neurology, Georgetown University Medical Center, Washington, DC, USA
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10
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Tejada J, Galiana A, Balboa Ó, Clavera B, Redondo-Robles L, Alonso N, Magadán V. Mechanical endovascular procedure for the treatment of acute ischemic stroke caused by total detachment of a papillary fibroelastoma. J Neurointerv Surg 2013; 6:e37. [DOI: 10.1136/neurintsurg-2013-010800.rep] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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11
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Tejada J, Galiana A, Balboa O, Clavera B, Redondo-Robles L, Alonso N, Magadán V. Mechanical endovascular procedure for the treatment of acute ischemic stroke caused by total detachment of a papillary fibroelastoma. BMJ Case Rep 2013; 2013:bcr-2013-010800. [PMID: 24000210 DOI: 10.1136/bcr-2013-010800] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Papillary fibroelastomas (PFEs) are rare cardiac tumors. Despite their benign nature, they are associated with a high risk of embolic complications including stroke. Endovascular treatment has been reported as a safe procedure in patients with myxoma, the most common type of primary cardiac tumor. A case of ischemic stroke due to embolization of a PFE successfully treated with a single pass of a retrievable stent is described. A 64-year-old patient with a right middle cerebral artery syndrome was treated with an intravenous and endovascular protocol as a revascularization procedure. Mechanical thrombectomy resulted in total recanalization with clinical improvement. Histological examination of the clot showed pathological features of a typical PFE. The endovascular treatment was safe and effective. With mechanical embolectomy it is possible to obtain and analyze pathological specimens, enabling the diagnosis of uncommon strokes.
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Affiliation(s)
- Javier Tejada
- Department of Neurology, Hospital de León, León, Spain.
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12
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Garcia-Ptacek S, Matias-Guiu JA, Valencia-Sánchez C, Gil A, Bernal-Becerra I, De las Heras-Revilla V, Serna-Candel C. Mechanical endovascular treatment of acute stroke due to cardiac myxoma. J Neurointerv Surg 2012; 6:e1. [PMID: 22791184 DOI: 10.1136/neurintsurg-2012-010343] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Myxomas are rare cardiac tumors which often present with stroke caused by tumorous or thrombotic emboli. Treatment with intravenous recombinant tissue plasminogen activator (rtPA) and intra-arterial thrombolysis has been described previously but mechanical thrombectomy has not yet been reported, and treatment of myxoma-related ischemic stroke remains a clinical and technical challenge. METHODS Two patients with ischemic stroke due to cardiac myxoma in which mechanical thrombectomy was performed are presented. RESULTS Endovascular thrombectomy after intravenous rtPA (bridging therapy) was safely achieved in both cases, although with different clinical outcomes and degrees of recanalization. CONCLUSIONS In stroke secondary to cardiac myxoma, mechanical thrombectomy might represent a safe and effective treatment option. The authors suggest the use of histological examination of the clot for diagnosis as its composition may explain the differences in treatment outcome.
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13
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da Silva IRF, de Freitas GR. Is It Safe to Proceed with Thrombolytic Therapy for Acute Ischemic Stroke in a Patient with Cardiac Myxoma Case Report and Review of the Literature. Eur Neurol 2012; 68:185-6. [DOI: 10.1159/000340019] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 06/10/2012] [Indexed: 11/19/2022]
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14
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Matijević V, Poljaković Z, Ilić I, Čikeš I, Habek M. Cardiac Papillary Fibroelastoma: Source of Cerebral Embolism Treated With Intravenous Thrombolysis. J Stroke Cerebrovasc Dis 2011; 20:485-7. [DOI: 10.1016/j.jstrokecerebrovasdis.2010.02.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Revised: 01/22/2010] [Accepted: 02/01/2010] [Indexed: 11/16/2022] Open
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15
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Chiang KH, Cheng HM, Chang BS, Chiu CH, Yen PS. Multiple cerebral aneurysms as manifestations of cardiac myxoma: Brain imaging, digital subtraction angiography, and echocardiography. Tzu Chi Med J 2011. [DOI: 10.1016/j.tcmj.2011.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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16
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Abstract
Cardiac myxoma is a rare but curable cause of ischemic stroke. Current guidelines do not address the use of intravenous thrombolysis for embolic stroke caused by cardiac myxoma. The risk of hemorrhage due to occult tumor emboli or microaneurysms is a major concern. We describe a 45-year-old man who had an embolic stroke in the left middle cerebral artery. The initial National Institutes of Health Stroke Scale (NIHSS) score was 16. He received intravenous thrombolysis 2 h and 52 min after stroke onset. No intracranial hemorrhage developed. A cardiac mass was found in the left atrium and removed surgically 84 h after stroke. Pathological study showed a myxoma with extensive hemorrhage and thrombus over the surface. At the 3-month follow-up, the NIHSS score was 9 and the modified Rankin scale score was 3. Our experience with this patient supports the hypothesis that intravenous thrombolysis may be safely used in the treatment of embolic stroke due to cardiac myxoma.
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Affiliation(s)
- Mu-Chien Sun
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan, ROC
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17
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Abe M, Kohama A, Takeda T, Ishikawa A, Yamada Y, Kawase Y, Ishii Y, Bessho R, Oaki Y, Haruta S, Ohashi T. Effective intravenous thrombolytic therapy in a patient with cerebral infarction associated with left atrial myxoma. Intern Med 2011; 50:2401-5. [PMID: 22001475 DOI: 10.2169/internalmedicine.50.5545] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 70-year-old man presented with sudden onset of global aphasia and right hemiplegia. Brain MRI revealed occlusion of the left middle cerebral artery. He was diagnosed as having a hyperacute cerebral infarction. Intravenous thrombolytic therapy was started, and the neurological symptoms were resolved after 11 h. Echocardiography showed a mobile mass in the left atrium, suspicious of a myxoma. The tumor was resected and pathologically diagnosed as a myxoma. In this patient, intravenous thrombolytic therapy was effective, and no adverse effects were observed. This suggests that, even with complications of myxoma, thrombolytic therapy can be considered if there are no contraindications.
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Affiliation(s)
- Mayumi Abe
- Department of Neurology, Tokyo Women's Medical University, Yachiyo Medical Center, Japan.
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18
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Ong CT, Chang RY. Intravenous thrombolysis of occlusion in the middle cerebral and retinal arteries from presumed ventricular myxoma. Stroke Res Treat 2010; 2011:735057. [PMID: 21151657 PMCID: PMC2997343 DOI: 10.4061/2011/735057] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 11/08/2010] [Indexed: 11/20/2022] Open
Abstract
Background. Although thrombolytic therapy has been shown to be beneficial to stroke patients, the effectiveness of intravenous thrombolysis in ischemic stroke patients with ventricle myxoma is unknown. Case Description. A 22-year-old woman with left hemiplegia was sent to the emergency department at a teaching hospital. The magnetic resonance angiography showed occlusion of the right middle cerebral artery, and the echocardiography showed a mass in the left ventricle. Intravenous recombined tissue plasminogen activator (rt-PA) was administrated, and the postthrombolysis transcranial Doppler exam showed that her right middle cerebral artery was circulative. The patient's condition improved gradually, and no complication was observed up to 16 months of follow-up. Conclusion. Intravenous rt-PA is a reasonable treatment for stroke patients with ventricle myxoma.
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Affiliation(s)
- Cheung-Ter Ong
- Department of Neurology, Chia-Yi Christian Hospital, 539 Chung-Shao Road, Chia-Yi 60002, Taiwan
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19
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Safe and effective intravenous thrombolysis for acute ischemic stroke caused by left atrial myxoma. J Stroke Cerebrovasc Dis 2009; 18:398-402. [PMID: 19717026 DOI: 10.1016/j.jstrokecerebrovasdis.2008.11.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Revised: 11/16/2008] [Accepted: 11/20/2008] [Indexed: 11/21/2022] Open
Abstract
Atrial myxoma may be associated with syncope or sudden death attributed to left-sided cardiac outflow obstruction or embolization caused by tumor dislodgement or thrombus formation. Definitive treatment for primary and secondary stroke prevention is surgical resection. The role of thrombolysis in acute brain ischemia in patients with atrial myxoma is not defined. There are few data available regarding safety and efficacy of thrombolytic therapy in acute ischemic strokes caused by atrial myxoma. Prior case reports described partial success using intra-arterial local thrombolysis; however, this is invasive and can be associated with significant complications. A previously reported case of systemic thrombolysis resulted in development of cerebral hemorrhage. We describe a young man who presented with syncope and a dense stroke developing as a complication of atrial myxoma, followed by a remarkable recovery after treatment with intravenous recombinant tissue plasminogen activator and urgent cardiac surgery. Contrary to some expert opinion, systemic thrombolytic therapy may be safely and effectively used to treat acute ischemic strokes from atrial myxoma.
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20
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de Almeida LA, Hueb JC, de Moraes Silva MA, Bazan R, Estrozi B, Raffin CN. Cerebral ischemia as initial neurological manifestation of atrial myxoma: case report. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 64:660-3. [PMID: 17119814 DOI: 10.1590/s0004-282x2006000400027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Accepted: 04/19/2006] [Indexed: 11/22/2022]
Abstract
Cerebral infarctions of cardiac etiology are observed in around 20% of patients with ischemic stroke. Cerebral ischemia is the first clinical manifestation in 1/3 of cases of atrial myxomas. Although almost half of patients with atrial myxoma show changes at neurological exam, non-hemorrhagic cerebral infarction is seen in computed tomography in practically all cases. We present the case of a 40 year-old woman whose first clinical manifestation of atrial myxoma was an ischemic stroke. We point out to the possibility of silent cerebral infarction in atrial myxoma patients.
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Chong JY, Vraniak P, Etienne M, Sherman D, Elkind MSV. Intravenous thrombolytic treatment of acute ischemic stroke associated with left atrial myxoma: A case report. J Stroke Cerebrovasc Dis 2005; 14:39-41. [PMID: 17903996 DOI: 10.1016/j.jstrokecerebrovasdis.2004.09.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2004] [Accepted: 09/22/2004] [Indexed: 11/20/2022] Open
Abstract
There are few data available regarding the safety or efficacy of thrombolysis of acute ischemic stroke secondary to myxoma. We present a patient treated with intravenous recombinant tissue plasminogen activator who developed hemorrhage remote from the location of ischemic stroke. Intra-arterial local thrombolysis may be a preferable alternative because of greater risk of hemorrhage from occult tumor emboli or microaneurysms in these patients.
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Affiliation(s)
- Ji Y Chong
- Department of Neurology, Neurological Institute, Columbia University Medical Center, New York, New York, USA
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22
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Gomez CR, Orr SC, Soto RD. Neuroendovascular Rescue: Interventional Treatment of Acute Ischemic Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2002; 4:405-419. [PMID: 12194813 DOI: 10.1007/s11936-002-0020-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Stroke continues to be a major health problem for our society. Despite the proven effectiveness of intravenous tissue plasminogen activator (t-PA) for the treatment of acute ischemic stroke, only a minority of patients qualify for this type of therapy. Furthermore, the existing literature has demonstrated that t-PA is not as effective in the treatment of occlusion of large cerebral arteries. The benefit-to-risk assessment of this subpopulation of stroke patients makes them the best candidates for neuroendovascular rescue. This term refers to the intra-arterial application of techniques designed to promote arterial recanalization, and includes intra-arterial thrombolysis and antithrombotic agents, direct mechanical disruption, angioplasty, stenting, embolectomy, and vasoactive pharmacologic intervention. The timing and choice of these procedures, as well as the care of the patient prior to, during, and after the intervention, requires a highly focused and expert approach.
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Affiliation(s)
- Camilo R. Gomez
- *University of Alabama at Birmingham, Comprehensive Stroke Center, 1202 Jefferson Tower, 625 South 19th Street, Birmingham, AL 35294, USA.
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23
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Jean WC, Walski-Easton SM, Nussbaum ES. Multiple Intracranial Aneurysms as Delayed Complications of an Atrial Myxoma: Case Report. Neurosurgery 2001. [DOI: 10.1227/00006123-200107000-00031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Jean WC, Walski-Easton SM, Nussbaum ES. Multiple intracranial aneurysms as delayed complications of an atrial myxoma: case report. Neurosurgery 2001; 49:200-2; discussion 202-3. [PMID: 11440443 DOI: 10.1097/00006123-200107000-00031] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE AND IMPORTANCE Atrial myxomas are rare cardiac tumors that may cause neurological complications; however, delayed neurological events after total tumor resection are rare. In this report, we present a patient who developed transient cerebral ischemic attacks and was found to have multiple intracranial aneurysms 5 years after successful resection of her atrial myxoma. At the time of myxoma resection, there were no neurological symptoms; at the time of presentation with transient ischemic attacks, there was no evidence of atrial recurrence. CLINICAL PRESENTATION A 32-year-old woman presented with five episodes of right arm and face paresthesia, each lasting 15 to 20 minutes, 5 years after successful resection of her atrial myxoma. Clopidogrel bisulfate therapy was initiated, with resolution of her symptoms. Angiography revealed multiple, peripherally located, fusiform cerebral aneurysms. INTERVENTION A left frontal craniotomy for resection and biopsy of one of the aneurysms was performed, to establish the diagnosis. Pathological analysis of the biopsied aneurysm provided evidence of direct atrial myxoma invasion and occlusion of the cerebral blood vessel. CONCLUSION Neurological symptoms may accompany or lead to the diagnosis of atrial myxoma. Rarely, as in this case, myxomatous aneurysms may develop years after definitive treatment of the primary tumor. Patients who have undergone successful resection of a left atrial myxoma may be at risk for delayed cerebral ischemia associated with aneurysm development, and this phenomenon must be considered for patients with neurological symptoms who present even years after myxoma removal. The natural history, pathophysiological features, and treatment dilemma of these aneurysms are discussed.
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Affiliation(s)
- W C Jean
- Department of Neurosurgery, University of Minnesota, Minneapolis 55455, USA
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Moreno Izarra J, Romero López A, Pinillos Villatoro D, Delgado Acosta F, Fernández de la Puebla R, Pérez Jiménez F. [Focal seizures in a young man with long term arthromyalgia and recurrent skin lesions. Cardiac myxoma. Neoplastic aneurysm and multiple cerebral infarct due to tumor embolization]. Rev Clin Esp 2000; 200:487-8. [PMID: 11111394 DOI: 10.1016/s0014-2565(00)70702-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- J Moreno Izarra
- Servicios de Medicina Interna, Hospital Universitario Reina Sofía, Córdoba
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26
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Gomez CR, Wadlington VR, Terry JB, Tulyapronchote R. Neuroendovascular rescue. Nonthrombolytic approach to acute brain ischemia. Crit Care Clin 1999; 15:755-76. [PMID: 10569120 DOI: 10.1016/s0749-0704(05)70086-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The field of neuroendovascular therapy is rapidly growing. New technology and operators' expertise is developing at a pace that will make this discipline progressively more available and successful. For the intensive care of patients who have acute brain ischemia, new techniques of recanalizing occluded arteries are progressively being introduced. Thus, the concept of neuroendovascular rescue has gone beyond the use of thrombolytic drugs, expanding our capability to restore flow to ischemic brain tissue after prolonged therapeutic windows. It is important for the interventionalist and the intensivist to work closely together to guarantee the most favorable outcome possible.
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Affiliation(s)
- C R Gomez
- Comprehensive Stroke Center, University of Alabama at Birmingham, USA
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