Recurrent Acute Limb Ischaemia due to Malignant Thromboembolism Involving Bilateral Lower Limbs Simultaneously

Figures

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  FIGURE 1. (A) CT Angiography (Arterial Phase) Showing Arterial Occlusion (Axial Slice). The green arrow shows a lack of contrast in distal brachial artery highlighting an occlusion in the artery. This is more easily appreciated in (B). This is a 3D Reconstruction of CT‐A of Upper Limb prior to the patient's first embolectomy. Please note the orange arrow highlighting the absence of continuity from the distal brachial artery to its bifurcation as it becomes the radial and ulnar arteries. This lack of continuity shows the absence of blood flow in the affected area.

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  FIGURE 2. Previous CT chest showing patients malignancy (green arrow).

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  FIGURE 3. H&E upper limb thrombus (×200 magnification. Haematoxylin and Eosin staining).

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  FIGURE 4. (A) CT‐A with lower limb runoff (further distal) showing occlusion of the right (orange arrow) as well as the left (blue arrow) popliteal artery. This is evident in the lack of contrast in the popliteal arteries shows that there is an occlusion at the level of the popliteal arteries bilaterally. (B) Saggital Views of Popliteal Artery Occlusions: Similarly to the axial views, there is a lack of contrast in the popliteal arteries in this view. (C) 3D Reconstruction of CT‐A of Lower Limbs prior to the patient's second operation. Please note both arrows highlighting the absence of continuity in this 3D reconstruction. On the patient's Right (blue arrow), this is from the origin of the popliteal artery to the origins of the anterior tibial artery and the tibioperoneal trunk. On the left (purple arrow) the second part of the popliteal artery is missing. The lack of continuity in the lower limb vasculature shows the absence of blood flow in the affected areas signifying occlusion.

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  FIGURE 5. (Clockwise) (A) (H&E, ×200 magnification) and (B) (H&E, x200 magnification) show the upper limb and lower limb thrombus on Haematoxylin and Eosin staining. At high power, the tumour cells have pleomorphic, hyperchromatic nuclei with nucleoli, scattered mitotic figures and dense eosinophilic cytoplasm. Focal dyskeratotic cells are seen. The tumour nests are surrounded by fibrin and haemorrhage. (C) Shows positive staining for P40 in the tumour cells, and (D) shows positive staining for AE1/AE3 in the tumour cells, in keeping with metastatic squamous cell carcinoma (×200 magnification).

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  FIGURE 6. (A) MRI‐B. 10 × 9 mm lesion in the right middle frontal gyrus centred at the grey‐white matter junction. The lesion demonstrates intrinsic T1 hyperintensity with no appreciable enhancement. There is surrounding T2/FLAIR signal hyperintensity involving the subcortical white matter and cortex. There is extensive SWI signal abnormality corresponding to calcification on prior CT. (B) MRI‐B. 19 mm medial left occipital lobe metastasis with mild vasogenic oedema.