Kamiya Yuki, Ichikawa Hiroo, Mizuma Keita, Itaya Kazuhiro, Shimizu Yuki, Kawamura Mitsuru
Department of Neurology, Showa University Fujigaoka Hospital.
Rinsho Shinkeigaku. 2014;54(6):502-6. doi: 10.5692/clinicalneurol.54.502.
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.
一名48岁既往无神经系统疾病的女性因突发意识丧失被转至我院。入院时，她存在意识障碍（格拉斯哥昏迷量表评分为E1V1M3）、四肢瘫、右眼共轭偏斜及双侧病理反射。这些症状导致美国国立卫生研究院卒中量表评分为32分。脑部弥散加权磁共振成像（DWI）显示多个高信号病灶，磁共振血管造影显示基底动脉（BA）及右侧大脑中动脉（MCA）上干闭塞。经胸超声心动图显示左心房有一个51×24mm的黏液瘤。这些发现导致诊断为心脏黏液瘤栓塞所致急性缺血性卒中。由于没有该治疗的禁忌证，在发病120分钟后开始静脉注射组织型纤溶酶原激活剂（IV tPA）进行溶栓治疗。然而，症状并未缓解，因此在IV tPA治疗后立即进行了血管内治疗。左侧椎动脉血管造影最初显示BA闭塞，但重复血管造影显示BA自发再通。然而，左侧大脑后动脉仍被残留栓子阻塞。随后，使用尿激酶进行动脉内局部溶栓及用异物取出装置进行取栓术治疗右侧MCA上干发现的闭塞，但MCA仍闭塞。血管内治疗后的DWI显示双侧内侧丘脑及左侧枕叶皮质出现新的高信号病灶。临床上，神经功能状态未改善，改良Rankin量表评分为5分。IV tPA可用于心脏黏液瘤所致卒中，但黏液瘤引起脑动脉瘤和转移的发生是一个问题。鉴于难以预测来自血栓或肿瘤颗粒的栓子组合，对于心脏黏液瘤所致卒中，抽吸取栓术可能更安全、更有效，以避免脑动脉瘤和转移的延迟形成。
