Cardiac Papillary Fibroelastoma: Source of Cerebral Embolism Treated With Intravenous Thrombolysis

doi:10.1016/j.jstrokecerebrovasdis.2010.02.013

Journal of Stroke and Cerebrovascular Diseases

Volume 20, Issue 5, September–October 2011, Pages 485-487

https://doi.org/10.1016/j.jstrokecerebrovasdis.2010.02.013 Get rights and content

We present the case of a 41-year-old man with sudden development of left hemiparesis due to infarction of the right middle cerebral artery that was successfully treated with intravenous (IV) thrombolysis with alteplase. Transthoracic echocardiography showed a small mass in the left ventricle. The patient underwent surgical resection, and histological examination of the mass confirmed the diagnosis of papillary fibroelastoma. It remains to be investigated whether heart ultrasound evaluation should be performed before IV thrombolysis in selected patients with stroke, given the apparently increased risk of bleeding. However, IV thrombolysis should not be postponed due to a lengthy investigation, because of its potential for reducing morbidity in patients with stroke.

Section snippets

Case Report

A 41-year-old man with no history of serious illness and no known cerebrovascular risk factors was admitted after sudden development of left hemiparesis. Brain multislice computed tomography (MSCT) showed no early signs of stroke (Fig 1, A). On evaluation, the patient was assigned a National Institutes of Health Stroke Scale (NIHSS) score of 13. According to our institution's protocol, we started thrombolysis with IV tissue plasminogen activator (tPA) at 105 minutes after symptom onset.

Discussion

Cardiac PFE is a rare primary cardiac tumor. Unlike in myxoma, embolization is uncommon.² It occurs mainly in persons over age 50 years, with no sex preference, and typically is asymptomatic or becomes evident during investigation after stroke.2, 3 Although rare, stroke is possible sequela of cardiac PFE. A fibrin thrombus attached to the edge of the PFE, as well as the PFE itself, can be sources of embolic material.² Similarily, emboli from atrial myxomas may be composed of thrombus, tumor

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Effective ADAPT Thrombectomy in a Patient with Acute Stroke due to Cardiac Papillary Elastofibroma: Histological Thrombus Confirmation
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Histologically confirmed tumor fragments have been isolated from the embolic material from coronary, pulmonary, and peripheral arteries, but not from cerebral embolism.2 Five cases are reported in literature in which PEF is supposed to be the stroke etiology treated with both IV3,4 and intra-arterial recombinant tissue plasminogen activator,5,6 and 2 of these cases are associated with mechanical disruption,6,7 but none of the 5 cases has the histological confirmation of the embolic material. In these cases, an indirect diagnosis of the embolic nature of the thombus was made by histological analysis after cardiac PEF removal.
A 75-year-old man with hypertension and atrial fibrillation was admitted to our emergency room with right-sided hemiplegia and complete aphasia (National Institutes of Health Stroke Scale [NIHSS] score = 18). A noncontrast computed tomography scan showed a slight hypodensity in the left insular region and a bright hyperdense sign in the M1 tract of the left middle cerebral artery (MCA). Angio-CT confirmed an occlusion of the M1 tract of the MCA. Magnetic resonance diffusion-weighted imaging/perfusion-weighted imaging was obtained and revealed a mismatch in the left parietal cortical region. Complete revascularization was achieved by thromboaspiration with the A Direct ASPIRATION first PASS TECHNIQUE (ADAPT) technique. Histological examination of the embolic material revealed its nonthrombotic nature: cardiac embolic papillary elastofibroma (PEF). At discharge, good recovery of right-side hemiplegia was observed. This case report is the second in literature in which a histological confirmed cardiac embolic PEF is reported as a cause of embolic stroke. PEF is a rare but potentially treatable cause of embolic stroke. Understanding the nature of the embolic material would help in choosing the best revascularization approach.
Stroke and cardiac papillary fibroelastoma: Mechanical thrombectomy after thrombolytic therapy
2014, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Because of its rarity, there are few data regarding safety and efficacy of thrombolytic therapy in acute ischemic strokes caused by CPF. Only 3 previous reports presented patients with acute ischemic stroke and associated CPF treated with thrombolytic therapy—1 received alteplase intravenously3 and 2 intra-arterially4,5—in one of them intra-arterially thrombolysis was combined with mechanical clot disruption.5 When embolization is from the thrombotic material surrounding the neoplasm, it could be successfully treated with alteplase; if the embolizing material is a fragment from the tumor, fibrinolytic therapy is probably futile.
We describe a case of a 34-year-old man with a sudden development of right hemiparesis and aphasia because of infarction of the left middle cerebral artery that was submitted to intravenous (IV) recombinant tissue plasminogen activator and mechanical thrombectomy. Transesophageal echocardiogram showed a small mass on the anterior leaflet of the mitral valve. Cardiac surgery was performed, and histological examination of the removed material was consistent with cardiac papillary fibroelastoma (CPF). Experience in using IV thrombolysis for the treatment of embolic stroke because of CPF is limited. To the best of our knowledge, only 3 patients are reported in literature in whom acute ischemic stroke and associated CPF were treated with thrombolytic therapy. A discussion of the efficacy of IV thrombolysis and the possible superiority of mechanical thrombectomy is included.
Neurologic complications of cardiac tumors
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Citation Excerpt :
Results of thrombolytic therapy in embolic stroke from atrial myxoma have been mixed. A few case reports have described successful treatment of stroke from probable embolic disease using intravenous thrombolysis (Nagy et al., 2009; Abe et al., 2011; Malijevic et al., 2011; Ong and Chang, 2011) and intra-arterial thrombolysis (Gassanov et al., 2011). Other authors have described lack of success or intracranial hemorrhage from both intravenous and interarterial thrombolysis in similar patients (Bekavac et al., 1997; Chong et al., 2005; Acampa et al., 2011; Kohno et al., 2012).
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.
The importance of early completion of cardiac investigations after ischaemic stroke: A case and systematic review of reperfusion therapy in stroke due to cardiac fibroelastoma
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Case ReportCardiac Papillary Fibroelastoma: Source of Cerebral Embolism Treated With Intravenous Thrombolysis

Section snippets

Case Report

Discussion

Am Heart J

J Stroke Cerebrovasc Dis

The organization of stroke services

Cardiac papillary fibroelastoma: An unusual source of cerebral embolism solved with local fibrinolysis

Neurol Sci

Case Report
Cardiac Papillary Fibroelastoma: Source of Cerebral Embolism Treated With Intravenous Thrombolysis