Cardiac intimal sarcoma presenting as basilar artery occlusion treated with tenecteplase and thrombectomy: a case report

Background Cardiac intimal sarcoma is a rare and aggressive malignancy, often presenting with embolic complications such as stroke. Basilar artery occlusion (BAO) is a life-threatening neurological emergency caused by several mechanisms, most commonly embolism (including cardioembolism) and intracranial atherosclerotic disease (with thrombotic occlusion). Case presentation A 77-year-old man with a history of coronary heart disease, cerebral infarction, and hypertension presented with acute speech impairment and progressive consciousness disturbance. NIHSS score was 28. The electrocardiogram showed atrial fibrillation. Non-contrast head computed tomography ruled out hemorrhage. Intravenous tenecteplase (22.5 mg) was administered before platelet count results were available, which later revealed thrombocytopenia (54 × 10⁹/L). Emergency mechanical thrombectomy retrieved a 4-cm thrombus from the basilar apex. Histopathology and immunohistochemistry confirmed a diagnosis of intimal sarcoma. Post-procedure, the patient developed multi-organ bleeding and coagulopathy, requiring continuous renal replacement therapy. Despite successful revascularization (NIHSS improved to 10), the patient succumbed to complications of advanced malignancy and hematologic dysfunction. Conclusions This case highlights that cardiac intimal sarcoma can present as acute BAO. Histopathological analysis of thrombectomy-retrieved embolic material can establish the diagnosis, obviating the need for invasive cardiac biopsy. Intravenous thrombolysis in the setting of unrecognized thrombocytopenia or malignancy-associated hemostatic dysfunction may carry substantial bleeding risk and warrants careful patient selection, urgent laboratory confirmation when feasible, and multidisciplinary management.