Mechanical endovascular treatment of acute stroke ...

Downloaded from http://jnis.bmj.com/ on January 10, 2016 - Published by group.bmj.com

Ischemic stroke

CASE REPORT

Mechanical endovascular treatment of acute stroke due to cardiac myxoma Sara Garcia-Ptacek,1 Jordi A Matias-Guiu,1 Cristina Valencia-Sánchez,1 Alberto Gil,2 Israel Bernal-Becerra,3 Virginia De las Heras-Revilla,1 Carmen Serna-Candel2 1

Department of Neurology, Hospital Clinico San Carlos, Madrid, Spain 2 Department of Neuroradiology, Hospital Clinico San Carlos, Madrid, Spain 3 Department of Anatomopathology, Hospital Clinico San Carlos, Madrid, Spain Correspondence to Dr Sara García-Ptacek, Department of Neurology, Hospital Clinico San Carlos c/ prof Martin Lagos s/n 28040, Madrid, Spain;saragptacek@ gmail.com Received 2 March 2012 Accepted 22 June 2012 Published Online First 12 July 2012

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.

Endovascular treatment for acute stroke is becoming increasingly available. It serves as an innovative and promising therapeutic approach, as well as a diagnostic strategy. We report two cases of acute ischemic stroke secondary to cardiac myxoma treated with mechanical thrombectomy.

CASE REPORTS Case 1

To cite: Garcia-Ptacek S, Matias-Guiu JA, ValenciaSánchez C, et al. J NeuroIntervent Surg 2014;6:e1.

A 45-year-old patient presented with left middle cerebral artery (MCA) syndrome and absence of detectable pulses in lower limbs. The National Institute of Health Stroke Scale (NIHSS) score was 22. Brain CT angiography revealed left M1 segment MCA occlusion. Intravenous recombinant tissue plasminogen activator (rtPA) was administered 1 h and 40 min after clinical onset, but no recanalization was achieved and clinical worsening to NIHSS 27 was observed. Diffusion-weighted imaging and angio-MRI showed acute bilateral infarction in the basal ganglia (figure 1A) and persistent left M1 occlusion. The endovascular procedure began 5 h after clinical presentation (figure 2A–F). Thrombectomy with retrievable stents was technically difficult because of significant resistance of the clot: four passes were performed with Solitaire FR Device 4×20 (Ev3, Plymouth, Minnesota, USA) and one with Trevo (Concentric Medical, Mountain View, California, USA) with no

Garcia-Ptacek S, et al. J NeuroIntervent Surg 2014;6:e1. doi:10.1136/neurintsurg-2012-010343

success. Stenting of both M1 and M2 with selfexpanding Wingspan 3×20 stent (Boston Scientific, Natick, Massachusetts, USA) and balloon-expandable PHAROS Vitesse stent (Micrus Endovascular, San Jose, California, USA) was performed, together with the administration of intravenous lysine acetylsalicylate (450 mg) and abciximab. Although transitory partial recanalization was achieved, subsequent development of acute stent thrombosis led to reocclusion of M1 (TICI 0) (figure 2B–E). The post-procedure NIHSS score was 31. Angiography showed bilateral iliac and distal aortic thrombosis which required embolectomy (figure 2F). The multiple cerebral and peripheral emboli suggested the possibility of tumorous emboli or hypercoagulability. Urgent echocardiography showed a mobile mass adhered to the mitral valve. Brain imaging 24 h after the stroke did not show hemorrhagic transformation (figure 1B). Cardiac tumor and peripheral embolus were identified as myxoma by histological examination (figure 3). At 3 months the NIHSS score was 19 and the modified Rankin Scale (mRS) score was 4.

Case 2 A 34-year-old patient presented with left MCA syndrome. The NIHSS score was 26. Brain angio-CT showed left M1 segment MCA occlusion. Intravenous rtPA was administered 3 h and 10 min after the onset of symptoms. The patient did not improve and endovascular treatment was performed at 6 h 30 min. Angiography showed occlusion of M1 and A2 segments (figure 4A). Thrombectomy with two passes of the Solitaire FR Device 4×20 was successful, achieving total recanalization (TICI 3) (figure 4). A tumorous origin of the thrombus was suspected during the procedure because of the gross appearance and consistency to the touch of the clot, and histology showed a tumorous embolus of myxoma that resulted in diagnosis prior to echocardiography (figure 3). A CT scan 24 h later did not show hemorrhagic transformation (figure 5B). At 3 months the NIHSS score was 3 and the mRS score was 2 (mild aphasia).

DISCUSSION Myxoma is the most frequent primary cardiac tumor and its neurological complications may develop in 12–45% of cases.1 2 Stroke is the most common of these complications, but aneurysm and brain metastasis may also occur.1 1 of 4


Ischemic stroke Figure 1 Parenchymal imaging. Case 1. (A) Pre-procedure diffusion-weighed MRI showing bilateral ( predominantly left) acute basal ganglia infarcts. (B) Post-procedure FLAIR MRI showing bilateral basal ganglia infarcts.

Embolization arises from myxomatous material, surface thrombi or both; 41% of histological myxoma samples have surface thrombi which, together with greater tumor mobility, have been potentially associated with emboli.1 3 Treatment with intravenous rtPA has been performed in some cases of stroke secondary to cardiac myxoma4–7 and a favourable functional outcome has been reported.4 5 However, data on hemorrhagic transformation and recanalization rates have not always been specified. On the other hand, successful intra-arterial thrombolysis with rtPA and urokinase has also been reported, achieving partial recanalization but no clinical improvement.8 To our knowledge, this is the first report of endovascular mechanical treatment of a stroke caused by myxoma. Treatment of the first case was difficult and unsuccessful but, in the second

case, it was relatively easy and led to a favourable outcome. Histological analysis of the first case showed a lesion that was of hard consistency and difficult to cut, consisting of neoplastic spindle cells densely interwoven with platelets and fibrin. The second case showed a paucicellular mesenchymal tumor containing abundant myxoid matrix with occasional spindle cells. Our hypothesis is that clot heterogeneity in stroke due to myxoma could explain the differences in treatment effectiveness. However, the endovascular approach was safe in both patients. In both cases histological examination proved to be an interesting and accessible diagnostic tool in the characterization of stroke aetiology9; an unusual cause was suspected during the procedure which was confirmed by pathology. In this way, relevant information is provided regarding the aetiology of the stroke, and it can therefore serve as a guide in the planning of

Figure 2 Case 1. (A) Angiography showing left M1 occlusion. (B) Unfolded retrievable stent in M2-M1 left middle cerebral artery. (C) Unfolded self-expandable stent in M1 segment. (D) Self-expandable and balloon-expandable stent in M1 segment. (E) Reocclusion of M1 segment. (F) Angiography showing bilateral and distal aortic thrombosis. 2 of 4



Ischemic stroke

Figure 3 Anatomopathology. (A) Case 1, H&E 10×. Neoplastic proliferation: loose spindle cells arranged in cords (arrow head) mixed with platelets (dotted arrow), inflammatory cells, endothelial cells, myofibroblasts and fibrin (arrow). (B) Case 2, H&E 20×. Paucicellular mesenchymal tumor with small spindle cells (arrow head) with ovoid hyperchromatic nuclei, eosinophilic cytoplasm with indistinct cell borders floating in an abundant myxoid matrix (arrow). (C) Case 1, 40×. Positive immunoreactivity for CD34 (yellow arrows). Immunoreactivity to cytokeratins, S-100 protein, Calretinin and CD31 were negative. (D) Case 2, 20×. Positive immunoreactivity for CD34 (black arrows). Immunoreactivity to cytokeratins, S-100 protein and CD31 were negative; calretinin was positive.

Figure 4 Case 2. Angiography. (A) M1 and A2 occlusion. (B) Unfolded stent in M1. (C) Attempting A2 recanalization. (D) Final result (successful recanalization).


3 of 4


Ischemic stroke Figure 5 Parenchymal imaging. Case 2. (A) Pre-procedure diffusion-weighed MRI showing acute left middle cerebral artery (MCA) infarct. (B) 24 h post-procedure CT scan showing oedema in the MCA territory without evidence of hemorrhage.

complementary studies that should be carried out and the secondary prevention that should be followed, avoiding subsequent complications.1 2 In conclusion, intravenous rtPA or intra-arterial fibrinolytics might be safe and effective in stroke secondary to myxoma,4–6 but the presence of associated microaneurysms may theoretically increase the hemorrhagic risk from fibrinolytics.1 However, data are still scarce. Therefore, in this clinical setting, mechanical thrombectomy could represent a safe approach. Its effectiveness, however, may be related to thrombus composition and tumorassociated hypercoagulability. Although clot composition is impossible to determine during the procedure, clot consistency is sometimes perceived by the neurointerventionist. We propose that devices such as Merci or Catch be placed distal to the thrombus, which we prefer for hard thrombi, and embolectomy with retrievable stents for surface thrombi combined with balloon-expandable stents for mixed clots. However, the most effective device required for each type of thrombus remains undetermined. Contributors SG-P, JAM-G and CV-S contributed to the treatment of the patients and writing and editing of the article. AG was the neurointerventionist for both patients and edited the article. IB-B did the anatomopathological characterization. VDH-R contributed to the clinical treatment of the patients and edited the article. CS-C clinically managed both patients, participated in neurointerventional treatment, supervised manuscript revision and edited the article.

4 of 4

Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES 1 2 3 4

5

6

7

8

9

Lee VH, Connolly HM, Brown RD Jr. Central nervous system manifestations of cardiac myxoma. Arch Neurol 2007;64:1115–20. Knepper LE, Biller J, Adams HP Jr, et al. Neurologic manifestations of atrial myxoma. A 12-year experience and review. Stroke 1988;19:1435–40. Wold LE, Lie J. Cardiac myxomas: a clinicopathologic profile. Am J Pathol 1980;101:219–40. Nagy CD, Levy M, Mulhearn TJ IV, et al. Safe and effective intravenous thrombolysis for acute ischemic stroke caused by left atrial myxoma. J Stroke Cerebrovasc Dis 2009;18:398–402. Ibrahim M, Iliescu C, Safi HJ, et al. Biatrial myxoma and cerebral ischemia successfully treated with intravenous thrombolytic therapy and surgical resection. Tex Heart Inst J 2008;35:193–5. 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. Chong JY, Vraniak P, Etienne M, et al. Intravenous thrombolytic treatment of acute ischemic stroke associated with left atrial myxoma: a case report. J Stroke Cerebrovasc Dis 2005;14:39–41. Bekavac I, Hanna JP, Wallace RC, et al. Intra-arterial thrombolysis of embolic proximal middle cerebral artery occlusion from presumed atrial myxoma. Neurology 1997;49:618–20. Marder VJ, Chute DJ, Starkman S, et al. Analysis of thrombi retrieved from cerebral arteries of patients with acute ischemic stroke. Stroke 2006;37:2086–93.



Mechanical endovascular treatment of acute stroke due to cardiac myxoma Sara Garcia-Ptacek, Jordi A Matias-Guiu, Cristina Valencia-Sánchez, Alberto Gil, Israel Bernal-Becerra, Virginia De las Heras-Revilla and Carmen Serna-Candel J NeuroIntervent Surg 2014 6: e1 originally published online July 12, 2012

doi: 10.1136/neurintsurg-2012-010343 Updated information and services can be found at: http://jnis.bmj.com/content/6/1/e1

These include:

References Email alerting service

Topic Collections

This article cites 9 articles, 2 of which you can access for free at: http://jnis.bmj.com/content/6/1/e1#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.

Articles on similar topics can be found in the following collections Ischemic stroke (288)

Notes

To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/