Key result
IV thrombolysis and EVT fail to improve neurological status in a cardiac myxoma stroke patient.
Why the study?
Stroke due to cardiac myxoma presents treatment challenges including risks of brain aneurysms and metastases, and optimal therapy is uncertain.
Case Report (n=1)
No
In acute ischemic stroke due to cardiac myxoma, aspiration thrombectomy may be safer and more effective than IV tPA and retrieval devices to avoid delayed formation of brain aneurysms and metastases.
May signal limited benefit of IV thrombolysis plus stent-retriever thrombectomy in myxoma stroke; hypothesis-generating for aspiration techniques.
A 48-year-old woman with no previous neurological diseases was transferred to our hospital because of sudden-onset unconsciousness. On arrival, she showed consciousness disturbance (E1V1M3 on the Glasgow Coma Scale), tetraplegia, right conjugate deviation and bilateral pathological reflexes. These symptoms resulted in a NIH stroke scale score of 32. Brain diffusion-weighted MR imaging (DWI) showed multiple hyper-intense lesions, and MR angiography revealed occlusions of the basilar artery (BA) and superior branch of the right middle cerebral artery (MCA). Transthoracic echocardiography disclosed a 51 × 24 mm myxoma in the left atrium. These findings led to diagnosis of acute ischemic stroke due to embolization from cardiac myxoma. Thrombolytic therapy with intravenous tissue plasminogen activator (IV tPA) was started 120 min after onset because there were no contraindications for this treatment. However, the symptoms did not resolve, and thus endovascular therapy was performed immediately after IV tPA. Angiography of the left vertebral artery initially showed BA occlusion, but a repeated angiogram resulted in spontaneous recanalization of the BA. However, the left posterior cerebral artery remained occluded by a residual embolus. Subsequently, occlusion found in the superior branch of the right MCA was treated by intra-arterial local thrombolysis using urokinase and thrombectomy with a foreign body retrieval device, but the MCA remained occluded. DWI after endovascular therapy showed new hyper-intense lesions in the bilateral medial thalamus and left occipital cortex. Clinically, neurological status did not improve, with a score of 5 on the modified Rankin Scale. IV tPA can be used for stroke due to cardiac myxoma, but development of brain aneurysms and metastases caused by myxoma is a concern. Given the difficulty of predicting an embolus composite from a thrombus or tumor particle, aspiration thrombectomy may be safer and more effective for stroke due to cardiac myxoma to avoid delayed formation of brain aneurysms and metastases.
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Kamiya et al. (2014) conducted a case report in Acute ischemic stroke due to cardiac myxoma (n=1). Intravenous tissue plasminogen activator (IV tPA) and endovascular therapy was evaluated on Clinical outcome (modified Rankin Scale). In a patient with acute ischemic stroke due to cardiac myxoma, intravenous thrombolysis and subsequent endovascular therapy failed to improve neurological status, resulting in a modified Rankin Scale score of 5.
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