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BRIEF REPORT
Year : 2021  |  Volume : 69  |  Issue : 3  |  Page : 707-710

Mechanical Thrombectomy in Embolic Cardiac Myxoma: Case Report and Literature Review


1 Department of Radio-diagnosis and Imaging, PGIMER, Chandigarh, India
2 Department of Neurology, PGIMER, Chandigarh, India
3 Department of Histopathology, PGIMER, Chandigarh, India

Date of Submission13-Apr-2020
Date of Decision06-Jul-2020
Date of Acceptance15-Jul-2020
Date of Web Publication24-Jun-2021

Correspondence Address:
Dr. Vikas Bhatia
Department of Radio-diagnosis and Imaging PGIMER Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.319216

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 » Abstract 


Myxomas are the most common cardiac tumors and present clinically with cardiac manifestations, systemic constitutional symptoms, and embolic events. Posterior circulation involvement occurs in approximately 20 percent of cerebral ischemic events.The endovascular technique is an established life-saving therapy for eligible patients upto 24 hours from symptom onset. However, the role of endovascular management in embolic atrial myxoma remains unknown with no international consensus guidelines for the management of stroke in such patient population. Here, we present a case report of an embolic posterior circulation stroke in a young female treated with mechanical thrombectomy at 23 hours from symptom onset. To the best of our knowledge, this is the first thrombectomy case in posterior circulation with embolism from myxoma. Further workup confirmed an atrial myxoma which was resected. We also review the previous cases with mechanical thrombectomy done in such cases.


Keywords: Embolism, myxoma, stroke, thrombectomy, Thrombolysis in cerebral infarction
Key Message: Mechanical thrombectomy for embolic stroke from cardiac myxoma is a safe and effective technique. Advantages over thrombolysis include high success rate, extended window time, ability to get histopathological diagnosis, and lower bleeding risk.


How to cite this article:
Bhatia V, Jain C, Ray S, Gupta O, Chatterjee D, Kumar A. Mechanical Thrombectomy in Embolic Cardiac Myxoma: Case Report and Literature Review. Neurol India 2021;69:707-10

How to cite this URL:
Bhatia V, Jain C, Ray S, Gupta O, Chatterjee D, Kumar A. Mechanical Thrombectomy in Embolic Cardiac Myxoma: Case Report and Literature Review. Neurol India [serial online] 2021 [cited 2021 Jul 24];69:707-10. Available from: https://www.neurologyindia.com/text.asp?2021/69/3/707/319216




Stroke is the sudden onset of neurological deficit persisting for more than 24 hours due to acute focal injury attributable to a vascular cause. It may be hemorrhagic or ischemic, the latter being more common and accounting for approximately 80 percent cases. Etiologically, ischemic strokes may occur from thrombotic occlusion (atherosclerosis) or embolic occlusion (artery to artery or cardiac). Ischemic strokes are classified as cryptogenic strokes, also known as embolic stroke of undetermined source (ESUS) when full standard evaluation including echocardiography (transthoracic or transesophageal) is negative. Cardioaortic embolic source contributes to a major burden of ischemic strokes. Common causes include intracardiac thrombi, atrial fibrillation or myocardial infarction, bacterial endocarditis, and atrial myxomas. Endovascular management is life saving (AHA/ASA 2019 Class I recommendation) in eligible stroke patients beyond the traditional time window of 6 hours according to DAWN and DEFUSE 3 trials.[1] However, these address the anterior circulation events. The posterior circulation strokes, traditionally are treated upto 24 hours according to NICE recommendations and AHA/ASA 2019 give class IIb recommendation for carefully selected patients.[1]


 » Case Report Top


A 42-year-old female was brought to our hospital emergency services with a history of sudden loss of consciousness and inability to follow commands since 23 hours. The patient had no other known comorbidities. On examination, she had left upper and lower limb weakness with a Glasgow coma score (GCS) of 9. She had aniscocoria with right-sided pin-point pupil. Clinical stroke scale (NIHSS) was 28/42. CT scan and CT angiography at admission showed hypodense infarcts in bilateral thalami and right cerebellar hemisphere with an occlusive thrombus at basilar top extending to bilateral posterior cerebral arteries (P1 segments, right more than left). Door to CT interpretation time was 15 minutes. The patient was shifted to MRI to assess the prognosis and posterior circulation aspects score on diffusion weighted imaging was 5/10 with the additional involvement of the paramedian midbrain [Figure 1]. A diffusion-FLAIR mismatch was present. On the basis of CT angiography findings and MRI, the patient was shifted to an angiography suite.DSA was performed using a right femoral puncture with a 7F (90cm) long sheath (Cook medical) placed in the left subclavian artery through which Neuron 6F guiding catheter (penumbra Inc.) was navigated into the distal left vertebral artery. A Headway 27 microcatheter (Microvention, Terumo) over traxcess microwire (Microvention, Terumo) was negotiated across the thrombus [Figure 2]a into the right PCA. Single pass mechanical thrombectomy using Trevo® XP 4 × 30 mm stentriever (Stryker)[Figure 2]b was performed. TICI3 reperfusion [Figure 2]c and [Figure 2]d was obtained with a door to reperfusion time of 1 hour and 15 minutes [Figure 2]. On the angiography table, the patient's GCS improved to 13/15.The patient was shifted to intensive care support and her NIHSS improved to 10/42 and 8/42 at 24 and 48 hours, respectively. Echocardiography and cardiac MRI [Figure 3]a and [Figure 3]b confirmed an atrial myxoma attached to the left atrium measuring 2.5 × 1.8 cm. She was operated after 1 month with confirmation of tissue diagnosis of myxoma [Figure 3]c and [Figure 3]d. The patient was discharged with an mRS score of 1 at 3 months follow up.
Figure 1: DW imaging shows a posterior circulation ASPECTS of 5

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Figure 2: (a) Diagnostic run of left VA shows the presence of filling defect suggestive of thrombus in distal basilar and proximal bilateral P1 PCA arteries. (b) Opened stentriever from P1 PCA to basilar artery (c and d) Complete recanalization of posterior circulation TICI 3

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Figure 3: (a and b) Cardiac MRI showing left atrial enhancing mass s/o myxoma (black arrow). (c) Cardiac tissue and myxoma tissue (100 × Hematoxylin and eosin stain, H and E) Cardiomyocytes (Blue arrow) and Myxoma (yellow).(d) Myxoma cells arranged in cords, in myxoid matrix. The myxoma cells are cytologically bland, having ovoid to plumped spindle cells. (400×, H and E stain) Myxoma cell (Blue arrow)

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 » Discussion Top


More than 75 percent of cardiac tumors are benign, and myxomas account for a majority of these tumors. Histopathologically, myxomas comprise of scattered cells originating from multipotent mesenchyma in mucopolysaccharide stroma.[2] The production of endothelial growth factors promotes early angiogenesis in these tumors.[3] The initial symptoms of left atrial myxoma include cardiac manifestations like arrhythmias, syncopal attacks, and heart failure. Constitutional symptoms like fever and weight loss are present in few patients. Embolic phenomenon occurs in 35 percent cases due to the friable nature of the tumor. The increased frequency of embolism is seen in smaller (less than 4.5 cm) softer tumors having an atypical location. An irregular tumor surface, high mean platelet volume or platelet count have also been linked as risk factors which increase the propensity for myxomatous embolism.[4] Atrial myxomas, despite having a female predisposition, embolize more frequently in males. High pressure in the left ventricle with subsequent tissue fragmentation, detachment of tumor, and dissemination of overlaying thrombi from the tumor surface are possible mechanisms of systemic and cerebral embolism.[5]

Systemic and cerebral emboli are life threatening, urgent detection with endovascular management of such cases is necessary to prevent mortality. The cerebrovascular emboli often lodge at bifurcation points and terminal arterial zones in contrast to primary thrombotic–atherosclerotic occlusions. Intravenous tissue plasminogen activator (tPA) has been tried[6] with limited success in few case reports.Based on limited data, AHA/ASA 2019 guidelines[1] give weak recommendation (Class IIb) for use of IV alteplase which “may be reasonable” or “may be considered” in the management of myxoma patients with severe disabling stroke. The presence of associated microaneurysms may theoretically increase the risk of cerebral hemorrhage, if alteplase is instituted. Also, tumor emboli are less likely to lyse upon thrombolytic therapy.

There are no current recommendations or guidelines for endovascular management in embolic myxoma patients having severe disabling stoke and large vessel occlusion. We performed emergent clot retrieval using a new generation stent retriever with a single pass in such a case and obtained good patient outcome. Previously published cases[7],[8],[9],[10],[11],[12] are summarized in [Table 1]. 7 out of 8 (87.5%) cases showed technical success (TICI2b/3) and good functional outcomes at 3 months. This in conjunction with our case establishes the efficacy and safety of endovascular management of embolic myxoma patients in modern era.
Table 1: Comparative evaluation of mechanical thrombectomy in embolic stroke from cardiac myxoma based on reported cases

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It can be seen from these reports that there is good clinical outcome,[7],[8],[9],[10],[11],[12] good reperfusion rate,[7],[8],[9],[10],[11],[12] ability to establish HPE analysis from retrieved clot,[7],[8],[9],[10],[11],[12] good outcomes with aspiration,[7] stentrievers[8],[12] or combination.[9],[10],[11] Furthermore, good recanalization/outcome was seen in MCA occlusion, ICA bifurcation, ICA occlusion, and posterior circulation.[7],[9],[10],[11],[12] present study

Good outcome was seen at delayed presentation too.[present study]

Furthermore, the management of detected atrial mass after endovascular management of an embolic event is controversial. The risk of hemorrhagic conversion of ischemic stroke on early antiplatelet institution must be weighed against the risk of recurrence of embolic stroke from cardiac mass. The tumor must be resected as early as possible for secondary stroke prevention and cardiovascular complications like sudden death.[13],[14] Also, postoperatively, patients should be kept on long-term follow up and serial echocardiography as recurrent myxomas occur in 2 to 5 percent cases after surgery.[15] This case report highlights the rarity of endovascular management in embolic stroke in cardiac myxoma patients and the need of clinicians to recognize such possible mechanisms of embolic stroke which if managed in the window period can be life saving for patients.

We can make the following assumptions for treatment options in embolic cardiac myxoma based on literature review:

IV t-PA:

  • Few studies showing favorable outcome
  • Presence of associated microaneurysms may theoretically increase the hemorrhagic risk.
  • Tumor emboli are less likely to lyse upon thrombolytic therapy and may containtumor/adherent thrombotic material/combination.


Mechanical thrombectomy:

  • Published cases have shown good clinical outcome and recanalization in these cases.
  • Ability to get histopathological confirmation.
  • Less chances of hemorrhagic transformation compared to IVT/IAT.
  • Can be used in out-of-window patients.
  • Both aspiration and stentrievers devices have been shown the ability to retrieve the clot.


Previous metanalysis have shown that both the stentriever first thrombectomy and aspiration-first thrombectomy were associated with comparable final reperfusion rates and functional outcome.[16] Advantages of Aspiration first techniques are shorter groin to reperfusion, less chances of clot migration and vessel perforation. Disadvantages include the requirement of rescue therapy in a significant proportion of cases. However, the ultimate clinical outcome was found to be same irrespective of whether aspiration or stentriever is used.[16]

In conclusion, all patients with young stroke must have screening for cardiac pathology. Mechanical thrombectomy is a safe and effective treatment option in myxoma related embolic large vessel occlusion strokes, even with delayed clinical presentation, high NIHSS scores, or with contraindications to IV tPA in eligible patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: A guideline for healthcare professionals from the American heart association/American stroke association. Stroke 2019;50:e344-418.  Back to cited text no. 1
    
2.
Pucci A, Gagliardotto P, Zanini C, Pansini S, di Summa M, Mollo F. Histopathologic and clinical characterization of cardiac myxoma: Review of 53 cases from a single institution. Am Heart J 2000;140:134-8.  Back to cited text no. 2
    
3.
Kono T, Koide N, Hama Y, Kitahara H, Nakano H, Suzuki J, et al. Expression of vascular endothelial growth factor and angiogenesis in cardiac myxoma: A study of fifteen patients. J Thorac Cardiovasc Surg 2000;119:101-7.  Back to cited text no. 3
    
4.
He D, Zhang Y, Liang Y, Ye S, Wang C, Kang B, et al. Risk factors for embolism in cardiac myxoma: A retrospective analysis. Med Sci Monit 2015;21:1146-54.  Back to cited text no. 4
    
5.
Wang Z, Chen S, Zhu M, Zhang W, Zhang H, Li H, et al. Risk prediction for emboli and recurrence of primary cardiac myxomas after resection. J Cardiothorac Surg 2016;11:22.  Back to cited text no. 5
    
6.
Sun M-C, Tai H-C, Lee C-H. Intravenous thrombolysis for embolic stroke due to cardiac myxoma. Case Rep Neurol 2011;3:21-6.  Back to cited text no. 6
    
7.
Baek SH, Park S, Lee NJ, Kang Y, Cho KH. Effective mechanical thrombectomy in a patient with hyperacute ischemic stroke associated with cardiac myxoma. J Stroke Cerebrovasc Dis 2014;23:e417-9.  Back to cited text no. 7
    
8.
Garcia-PtacekS, Matias-GuiuJA, Valencia-SánchezC, Gil A, Bernal-Becerra I, De las Heras-Revilla V, et al.Mechanical endovascular treatment of acute stroke due to cardiac myxoma.J Neurointerv Surg 2014;6:e1.  Back to cited text no. 8
    
9.
Ryu B, Ishikawa T, Sato S, Yokote A, Nakamoto H, Nie M, et al. Mechanical endovascular recanalization in a patient with middle cerebral artery occlusion by tumorous emboli originating from cardiac myxoma. NMC Case Rep J 2015;2:53-6.  Back to cited text no. 9
    
10.
Vega RA, Chan JL, Anene-Maidoh TI, Grimes MM, Reavey-Cantwell JF.Mechanical thrombectomy for pediatric stroke arising from an atrial myxoma: Case report. J Neurosurg Pediatr 2015;15:301-5.  Back to cited text no. 10
    
11.
Uneda A, Suzuki K, Hirashita K, Yoshino K.Tandem cervical/intracranial internal carotid artery occlusion due to cardiac myxoma treated successfully with mechanical endovascular thrombectomy.Acta Neurochir (Wien) 2016;158:1393-5.  Back to cited text no. 11
    
12.
Zander T, Maynar J, López-Zárraga F, Herrera R, Timiraos-Fernández JJ, Saraceni A, et al. Mechanical thrombectomy in patients with tumour-related ischaemic stroke. Interv Neuroradiol 2016;22:705-8.  Back to cited text no. 12
    
13.
Keeling I. Cardiac myxomas: 24 years of experience in 49 patients. Eur J Cardiothorac Surg 2002;22:971-7.  Back to cited text no. 13
    
14.
Vassiliadis N, Vassiliadis K, Karkavelas G. Sudden death due to cardiac myxoma. Med Sci Law 1997;37:76-8.  Back to cited text no. 14
    
15.
Pinede L, Duhaut P, Loire R. Clinical presentation of left atrial cardiac myxoma: A series of 112 consecutive cases. Medicine 2001;80:159-72.  Back to cited text no. 15
    
16.
Tsang COA, Cheung IHW, Lau KK, Brinjikji W, Kallmes DF, Krings T. Outcomes of stent retriever versus aspiration-first Thrombectomy in ischemic stroke: A systematic review and meta-analysis. Am J Neuroradiol 2018;39:2070-6.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
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