Journal of the Neurological Sciences 353 (2015) 172–174
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Letter to the editor Extraction of tumour embolus following ★ perioperative stroke☆,☆☆,
Keywords: Stroke Perioperative stroke Tumour embolus Oncology Angiography Thrombectomy
We would like to highlight the case of a 69-year old man who was found to have a rare cause of perioperative stroke. The patient was diagnosed with primary adenocarcinoma of the lung, with no evidence of metastases on staging PET CT. His only past medical history was of hypertension. He underwent resection of the left upper lobe tumour. During the six-hour operation, hypotension or hypoxia was not encountered but supraventricular tachycardia was noted both intra- and postoperatively. In the recovery ward, he was noted to have new left-sided limb weakness. It was presumed that intra-operative stroke had occurred but the time of onset could not be ascertained. On urgent assessment by the neurology team, he was found to have a left hemiplegia with neglect and mild dysarthria and the National Institutes of Health Stroke Scale (NIHSS) was 16. CT brain showed acute ischaemic change in the right cerebral hemisphere and on CT angiography a filling defect was visible in the right middle cerebral artery (MCA). CT perfusion suggested the presence of a relatively small infarct core with a significantly larger penumbra in the right MCA territory. Formal angiography and mechanical clot retrieval were performed within one hour of initial assessment. A significant amount of material was extracted and angiographic recanalization was achieved (see Fig. 1, panel A–D). As the ‘clot’ had an unusual appearance, it was sent for histopathological analysis, revealing metastatic lung adenocarcinoma within the right MCA (see Fig. 1, panel E–F). The patient was transferred to the High Dependency Unit and subsequently to the Stroke Unit. CT brain was performed 24 h after angiography and this showed infarction in the right MCA territory (Fig. 1, panel G–H). Unfortunately there was no improvement in the NIHSS at this time or on reassessment of the NIHSS 30 days later. The postoperative course was complicated by collapse and consolidation in the residual left lung. Unfortunately, death occurred due to hospitalacquired pneumonia at 35 days post-stroke.
☆ Disclosures: The authors report no disclosures or conflicts of interest in relation to the manuscript. ☆☆ Dr Hughes has received educational grants and travel support for conferences from Biogen Idec, Merck Serono, Sanofi and Novartis. Dr Hunt reports no disclosures. ★ Author contributions: Dr Hughes drafted the manuscript and edited the images. Dr Hunt reviewed the manuscript.
http://dx.doi.org/10.1016/j.jns.2015.03.034 0022-510X/© 2015 Elsevier B.V. All rights reserved.
Perioperative stroke is a recognised complication of surgery and is usually ischaemic, due to thromboembolism or intraoperative hypotension. In this case, intravenous tissue plasminogen activator (tPA) was contra-indicated due to the risk of postoperative haemorrhage. The presumed ‘thrombus’ visualised on CT angiography and CT perfusion findings suggested that mechanical thrombectomy would be of potential benefit. Despite recanalization, there was no clinical improvement. The most significant factor confounding the outcome in this case was thought to be time since onset of stroke, as this may have been as long as 6 h. Systemic tumour embolism has most frequently been described with primary or secondary lung neoplasms and cardiac tumours such as left atrial myxoma. In most cases in the literature described with lung tumours, embolism has occurred intra- or immediately post-operatively [1–5] and very rarely spontaneously. To our knowledge, this is the only published case of mechanical tumour embolectomy performed for acute ischaemic stroke in the immediate post-operative period. Two other reported cases of tumour embolus causing ischaemic stroke have included histopathological confirmation following endovascular embolectomy [6,7]. Both presented with stroke due to spontaneous tumour embolus. In the case of a 22-year old female with malignant melanoma and intracranial metastases, intravenous thrombolysis was felt to be contra-indicated due to the risk of intracerebral haemorrhage. Angiography was performed and left MCA thrombus was extracted resulting in complete recanalization within 30 min. Her NIHSS improved from an initial score of 4 to a score of 1 at 24 h post-onset [6]. A 62-year old woman with breast cancer developed rightsided weakness and CT brain with perfusion studies suggested ischaemia in multiple arterial territories within the left cerebral hemisphere. Mechanical thrombectomy was undertaken and there was with partial recanalization which did not include the left MCA territory. The initial NIHSS score was 19 and the patient had motor aphasia and right hemiplegia following extubation post-angiography. Histopathology was consistent with a highgrade phyllodes tumour of breast [7]. Although rare, tumour embolism should be considered as the potential aetiology of perioperative stroke, especially following cancer surgery, as mechanical embolectomy should be contemplated. References [1] Brown DV, Faber LP, Tuman KJ. Perioperative stroke caused by arterial tumor embolism. Anesth Analg 2004;98:806. [2] Whyte RI, Starkey TD, Orringer MB. Tumor emboli from lung neoplasms involving pulmonary vein. J Thorac Cardiovasc 1992;104:421. [3] Schneiderman J, Lieberman Y, Adar R. Multiple tumor emboli after lung resection. J Cardiovasc Surg (Torino) 1989;30:496. [4] Mansour KA, Malone CE, Craver JM. Left atrial tumor embolism during pulmonary resection: Report of two cases. Ann Thorac Surg 1988;46:455. [5] Lefkovitz NW, Roessmann U, Kori SH. Major cerebral infarction from tumor embolus. Stroke 1986 May–Jun;17(3):555–7. [6] Kim CS, Jung HR, Cho KH, Chang HW, Sohn SI, Choi TH, Cho YW, Sohn CH. Forcedsuction thrombectomy of an arterial tumor embolism due to metastatic melanoma. Arch Neurol 2012 Feb;69(2):272–3.
Letter to the editor
173
Fig. 1. Brain imaging and angiography (before and after mechanical clot retrieval) and gross and histopathological images of the extracted material. (A) Initial CT brain showed acute ischaemic change in the right cerebral hemisphere and on CT angiography a filling defect was visible in the right MCA (B). Formal angiography (C) and mechanical clot retrieval was performed, achieving angiographic recanalization (D). (E) Photograph of the material extracted during mechanical clot retrieval from the right MCA. (F) Haematoxylin and eosin stain of the extracted material showing metastatic lung adenocarcinoma within the right MCA. (G–H) Repeat CT brain 24 h post-angiography shows infarction in the territory of the right MCA. [7] Bhatia S, Ku A, Pu C, Wright DG, Tayal AH. Endovascular mechanical retrieval of a terminal internal carotid artery breast tumor embolus. J Neurosurg 2010 Mar; 112(3):572–4.
Stephen J. Hunt Department of Neurology, Royal Victoria Hospital, Belfast, UK
Stella E. Hughes⁎ Annemarie Hunter Jamie Campbell
Aidan Brady Department of Pathology, Royal Victoria Hospital, Belfast, UK
174
Letter to the editor
Brian Herron Department of Neuropathology, Royal Victoria Hospital, Belfast, UK Graham Smyth Ian Rennie Department of Neuroradiology, Royal Victoria Hospital, Belfast, UK
⁎Corresponding author at: Department of Neurology, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, UK. Tel.: +44 2890634325. E-mail address: [email protected] (S. E. Hughes). 23 November 2014
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Letter to the editor Extraction of tumour embolus following ★ perioperative stroke☆,☆☆,
Keywords: Stroke Perioperative stroke Tumour embolus Oncology Angiography Thrombectomy
We would like to highlight the case of a 69-year old man who was found to have a rare cause of perioperative stroke. The patient was diagnosed with primary adenocarcinoma of the lung, with no evidence of metastases on staging PET CT. His only past medical history was of hypertension. He underwent resection of the left upper lobe tumour. During the six-hour operation, hypotension or hypoxia was not encountered but supraventricular tachycardia was noted both intra- and postoperatively. In the recovery ward, he was noted to have new left-sided limb weakness. It was presumed that intra-operative stroke had occurred but the time of onset could not be ascertained. On urgent assessment by the neurology team, he was found to have a left hemiplegia with neglect and mild dysarthria and the National Institutes of Health Stroke Scale (NIHSS) was 16. CT brain showed acute ischaemic change in the right cerebral hemisphere and on CT angiography a filling defect was visible in the right middle cerebral artery (MCA). CT perfusion suggested the presence of a relatively small infarct core with a significantly larger penumbra in the right MCA territory. Formal angiography and mechanical clot retrieval were performed within one hour of initial assessment. A significant amount of material was extracted and angiographic recanalization was achieved (see Fig. 1, panel A–D). As the ‘clot’ had an unusual appearance, it was sent for histopathological analysis, revealing metastatic lung adenocarcinoma within the right MCA (see Fig. 1, panel E–F). The patient was transferred to the High Dependency Unit and subsequently to the Stroke Unit. CT brain was performed 24 h after angiography and this showed infarction in the right MCA territory (Fig. 1, panel G–H). Unfortunately there was no improvement in the NIHSS at this time or on reassessment of the NIHSS 30 days later. The postoperative course was complicated by collapse and consolidation in the residual left lung. Unfortunately, death occurred due to hospitalacquired pneumonia at 35 days post-stroke.
☆ Disclosures: The authors report no disclosures or conflicts of interest in relation to the manuscript. ☆☆ Dr Hughes has received educational grants and travel support for conferences from Biogen Idec, Merck Serono, Sanofi and Novartis. Dr Hunt reports no disclosures. ★ Author contributions: Dr Hughes drafted the manuscript and edited the images. Dr Hunt reviewed the manuscript.
http://dx.doi.org/10.1016/j.jns.2015.03.034 0022-510X/© 2015 Elsevier B.V. All rights reserved.
Perioperative stroke is a recognised complication of surgery and is usually ischaemic, due to thromboembolism or intraoperative hypotension. In this case, intravenous tissue plasminogen activator (tPA) was contra-indicated due to the risk of postoperative haemorrhage. The presumed ‘thrombus’ visualised on CT angiography and CT perfusion findings suggested that mechanical thrombectomy would be of potential benefit. Despite recanalization, there was no clinical improvement. The most significant factor confounding the outcome in this case was thought to be time since onset of stroke, as this may have been as long as 6 h. Systemic tumour embolism has most frequently been described with primary or secondary lung neoplasms and cardiac tumours such as left atrial myxoma. In most cases in the literature described with lung tumours, embolism has occurred intra- or immediately post-operatively [1–5] and very rarely spontaneously. To our knowledge, this is the only published case of mechanical tumour embolectomy performed for acute ischaemic stroke in the immediate post-operative period. Two other reported cases of tumour embolus causing ischaemic stroke have included histopathological confirmation following endovascular embolectomy [6,7]. Both presented with stroke due to spontaneous tumour embolus. In the case of a 22-year old female with malignant melanoma and intracranial metastases, intravenous thrombolysis was felt to be contra-indicated due to the risk of intracerebral haemorrhage. Angiography was performed and left MCA thrombus was extracted resulting in complete recanalization within 30 min. Her NIHSS improved from an initial score of 4 to a score of 1 at 24 h post-onset [6]. A 62-year old woman with breast cancer developed rightsided weakness and CT brain with perfusion studies suggested ischaemia in multiple arterial territories within the left cerebral hemisphere. Mechanical thrombectomy was undertaken and there was with partial recanalization which did not include the left MCA territory. The initial NIHSS score was 19 and the patient had motor aphasia and right hemiplegia following extubation post-angiography. Histopathology was consistent with a highgrade phyllodes tumour of breast [7]. Although rare, tumour embolism should be considered as the potential aetiology of perioperative stroke, especially following cancer surgery, as mechanical embolectomy should be contemplated. References [1] Brown DV, Faber LP, Tuman KJ. Perioperative stroke caused by arterial tumor embolism. Anesth Analg 2004;98:806. [2] Whyte RI, Starkey TD, Orringer MB. Tumor emboli from lung neoplasms involving pulmonary vein. J Thorac Cardiovasc 1992;104:421. [3] Schneiderman J, Lieberman Y, Adar R. Multiple tumor emboli after lung resection. J Cardiovasc Surg (Torino) 1989;30:496. [4] Mansour KA, Malone CE, Craver JM. Left atrial tumor embolism during pulmonary resection: Report of two cases. Ann Thorac Surg 1988;46:455. [5] Lefkovitz NW, Roessmann U, Kori SH. Major cerebral infarction from tumor embolus. Stroke 1986 May–Jun;17(3):555–7. [6] Kim CS, Jung HR, Cho KH, Chang HW, Sohn SI, Choi TH, Cho YW, Sohn CH. Forcedsuction thrombectomy of an arterial tumor embolism due to metastatic melanoma. Arch Neurol 2012 Feb;69(2):272–3.
Letter to the editor
173
Fig. 1. Brain imaging and angiography (before and after mechanical clot retrieval) and gross and histopathological images of the extracted material. (A) Initial CT brain showed acute ischaemic change in the right cerebral hemisphere and on CT angiography a filling defect was visible in the right MCA (B). Formal angiography (C) and mechanical clot retrieval was performed, achieving angiographic recanalization (D). (E) Photograph of the material extracted during mechanical clot retrieval from the right MCA. (F) Haematoxylin and eosin stain of the extracted material showing metastatic lung adenocarcinoma within the right MCA. (G–H) Repeat CT brain 24 h post-angiography shows infarction in the territory of the right MCA. [7] Bhatia S, Ku A, Pu C, Wright DG, Tayal AH. Endovascular mechanical retrieval of a terminal internal carotid artery breast tumor embolus. J Neurosurg 2010 Mar; 112(3):572–4.
Stephen J. Hunt Department of Neurology, Royal Victoria Hospital, Belfast, UK
Stella E. Hughes⁎ Annemarie Hunter Jamie Campbell
Aidan Brady Department of Pathology, Royal Victoria Hospital, Belfast, UK
174
Letter to the editor
Brian Herron Department of Neuropathology, Royal Victoria Hospital, Belfast, UK Graham Smyth Ian Rennie Department of Neuroradiology, Royal Victoria Hospital, Belfast, UK
⁎Corresponding author at: Department of Neurology, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, UK. Tel.: +44 2890634325. E-mail address: [email protected] (S. E. Hughes). 23 November 2014
