- Stroke Center, Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
- Stroke Center, Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
- Stroke Center, Department of Neurology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
- Department of Respiratory Medicine, Comprehensive Cancer Center, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
- Department of Pathology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
Correspondence Address:
Tomoya Kamide
Stroke Center, Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
DOI:10.25259/SNI_37_2020
Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Shinichiro Yoshikawa1,2, Tomoya Kamide1, Shigen Kasakura2, Noriko Arai3, Takashi Osada3, Atsuto Mouri4, Mei Hamada5, Tomonori Kawasaki5, Masaki Takao3, Shinya Kohyama2. A case of cerebral infarction due to pleomorphic carcinoma of the lung. 01-Aug-2020;11:217
How to cite this URL: Shinichiro Yoshikawa1,2, Tomoya Kamide1, Shigen Kasakura2, Noriko Arai3, Takashi Osada3, Atsuto Mouri4, Mei Hamada5, Tomonori Kawasaki5, Masaki Takao3, Shinya Kohyama2. A case of cerebral infarction due to pleomorphic carcinoma of the lung. 01-Aug-2020;11:217. Available from: https://surgicalneurologyint.com/surgicalint-articles/10171/
Abstract
Background: With the increase in endovascular treatment, reports of embolism other than thrombus are scattered, but intracranial tumorigenic embolism is rare and difficult to diagnose. Here, we describe a case of a tumorigenic embolism in a patient with lung cancer whose invasion into the vascular system was not detected on preoperative whole-body imaging.
Case Description: A 66-year-old man who was hospitalized to undergo radiotherapy for pulmonary carcinoma suddenly developed left hemiplegia. He exhibited atrial fibrillation, and emergent radiographic examination revealed a right middle cerebral artery occlusion. Urgent mechanical embolectomy was performed, with successful revascularization. The excised embolus had a unique morphology and was pathologically diagnosed as a cerebral embolism caused by pleomorphic pulmonary carcinoma.
Conclusion: Tumor-derived cerebral embolism is extremely rare, but it is necessary to consider it as a potential source of embolism during differential diagnosis in patients with malignant tumors.
Keywords: Cerebral embolism, Cerebral infarction, Hemiplegia, Pleomorphic carcinoma
INTRODUCTION
Intracranial tumorigenic embolism is rare and difficult to diagnose. Several authors reported that it can be suspected based on primary tumor biopsy or nonintracranial embolism and confirmed in autopsies.[
MEDICAL HISTORY AND EXAMINATION
A 66-year-old man developed dyspnea and underwent bronchoscopy and lung biopsy at a local hospital. Lung carcinoma was suspected (pleomorphic lung carcinoma, cT4N3M0). He was referred to our institute and hospitalized to undergo palliative radiotherapy to prevent airway obstruction due to tumor invasion. Enhanced computed tomography (CT) performed on admission and after intervention did not reveal any emboli migrating into the pulmonary vein [
Figure 2:
(a) Diffusion-weighted magnetic resonance image of the brain depicting high-intensity signals in the area of the right internal cerebral artery (Alberta Stroke Program Early Computed Tomography Score of 5). (b) Angiography image showing occlusion of the middle cerebral artery (posteroanterior view). (c) Postthrombectomy right internal carotid artery angiography image demonstrating recanalization of the middle cerebral artery. (d) Excised tumor tissue consisted of a single mass that was reddish- white in color, cylindrical in shape, and exhibited elasticity.
INTERVENTION
The patient did not receive intravenous tissue plasminogen activator therapy because he had terminal cancer. Emergency cerebral angiography revealed a right MCA occlusion at the M1 distal segment [
POSTINTERVENTION COURSE
The day after the intervention, the patient’s neurological symptoms improved substantially. Only slight hemiplegia remained and he could walk unassisted. At 35 days after cerebral embolism onset, his Modified Rankin Scale score was 1 and he was discharged from the hospital. His performance status was maintained and chemotherapy for the lung carcinoma was initiated.
PATHOLOGY
The embolus excised from the intracranial vessel was 8 cm long and cylindrical, and pathological examination revealed central necrosis in the cross-sectional plane [
DISCUSSION
The most frequent cause of cerebrovascular malignant tumorigenic embolism is primary lung carcinoma, and the source of the embolus is often invasive carcinoma cells migrating into the pulmonary vein.[
A case of cerebral embolism caused by pleomorphic carcinoma (sarcoma-like malignant tumor) was reported previously, but the mechanisms causing the embolism were not investigated.[
Murai et al.[
The few reports that exist on the treatment of intracranial vascular tumorigenic embolism suggest that the prognosis is poor. Fortunately, in our patient, revascularization was achieved during the early phase of disease onset, resulting in a favorable clinical outcome. Elucidating the embolism’s source is essential for preventing recurrence. The central necrosis we noted through pathologic examination implies the involvement of a highly proliferative entity, which may cause frequent repeated embolism.[
CONCLUSION
Herein, we described a case of tumorigenic cerebral embolism associated with a rare form of lung carcinoma and pleomorphic carcinoma. Excised tumor tissue exhibited a long cylindrical shape, and central necrosis was detected through pathological assessment. Early and aggressive intravascular intervention may be effective in cases of tumorigenic embolus.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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