Cerebral tumor embolism from thyroid cancer treated by mechanical thrombectomy: illustrative case

Yuta Fujiwara Department of Neurosurgery, Shimane University Hospital, Izumo, Shimane, Japan; and

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Kentaro Hayashi Advanced Stroke Center, Shimane University Hospital, Izumo, Shimane, Japan

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Yohei Shibata Department of Neurosurgery, Shimane University Hospital, Izumo, Shimane, Japan; and

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Tatsuya Furuta Department of Neurosurgery, Shimane University Hospital, Izumo, Shimane, Japan; and

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Tomohiro Yamasaki Department of Neurosurgery, Shimane University Hospital, Izumo, Shimane, Japan; and

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Kazuhiro Yamamoto Advanced Stroke Center, Shimane University Hospital, Izumo, Shimane, Japan

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Masahiro Uchimura Department of Neurosurgery, Shimane University Hospital, Izumo, Shimane, Japan; and

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Fumio Nakagawa Department of Neurosurgery, Shimane University Hospital, Izumo, Shimane, Japan; and

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Mizuki Kambara Department of Neurosurgery, Shimane University Hospital, Izumo, Shimane, Japan; and

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Hidemasa Nagai Department of Neurosurgery, Shimane University Hospital, Izumo, Shimane, Japan; and

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Yasuhiko Akiyama Department of Neurosurgery, Shimane University Hospital, Izumo, Shimane, Japan; and

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BACKGROUND

Development in mechanical thrombectomy is progressing dramatically. Tumor embolism has been rarely reported on the basis of pathological study of the retrieved thrombus. Herein, the authors report a case of cerebral tumor embolism from advanced thyroid cancer, which was successfully treated with mechanical thrombectomy.

OBSERVATIONS

A 57-year-old man was diagnosed with thyroid cancer with multiple lung metastases and chemotherapy was planned. He experienced left hemiparesis and was bought to the emergency section of the authors’ hospital. Magnetic resonance angiography revealed right internal carotid artery occlusion and endovascular treatment was performed. Using a combination of aspiration catheter and stent retriever, white jelly-like embolus was retrieved. The pathological study demonstrated thyroid cancer embolism. Pulmonary vein invasion following lung metastasis of thyroid cancer was most presumably the cause of the tumor embolism.

LESSONS

Lung metastasis invading the pulmonary vein may be a cause of tumor embolism. Mechanical thrombectomy using a combination of stent retriever and aspiration catheter is effective in removing the tumor embolus and the pathological examination of the embolus is essential.

ABBREVIATIONS

CT = computed tomography; ICA = internal carotid artery; MCA = middle cerebral artery; rt-PA = recombinant tissue plasminogen activator

BACKGROUND

Development in mechanical thrombectomy is progressing dramatically. Tumor embolism has been rarely reported on the basis of pathological study of the retrieved thrombus. Herein, the authors report a case of cerebral tumor embolism from advanced thyroid cancer, which was successfully treated with mechanical thrombectomy.

OBSERVATIONS

A 57-year-old man was diagnosed with thyroid cancer with multiple lung metastases and chemotherapy was planned. He experienced left hemiparesis and was bought to the emergency section of the authors’ hospital. Magnetic resonance angiography revealed right internal carotid artery occlusion and endovascular treatment was performed. Using a combination of aspiration catheter and stent retriever, white jelly-like embolus was retrieved. The pathological study demonstrated thyroid cancer embolism. Pulmonary vein invasion following lung metastasis of thyroid cancer was most presumably the cause of the tumor embolism.

LESSONS

Lung metastasis invading the pulmonary vein may be a cause of tumor embolism. Mechanical thrombectomy using a combination of stent retriever and aspiration catheter is effective in removing the tumor embolus and the pathological examination of the embolus is essential.

ABBREVIATIONS

CT = computed tomography; ICA = internal carotid artery; MCA = middle cerebral artery; rt-PA = recombinant tissue plasminogen activator

Cancer activates blood coagulation and results in cancer-associated cerebral infarction. In addition, cancer may invade the blood vessels and induce tumor embolism. It is reported that the rate of cerebral tumor embolism with a malignant tumor is as high as 4.7%.1 Herein, we report a case of thyroid cancer embolism retrieved with mechanical thrombectomy and review the literature on tumor embolism recanalized with endovascular treatment.

Illustrative Case

A 57-year-old man was diagnosed with an advanced stage of thyroid cancer. Multiple lung metastases were found, and chemotherapy was planned. He experienced left hemiparesis when he woke up and was brought to our hospital’s emergency department. Neurological examination showed mild disturbance in consciousness and left hemiplegia. His National Institutes of Health Stroke Scale Score was 11 points. His pulse rate was regular. Blood test revealed d-dimer in the normal range (0.7 μg/dL). Brain computed tomography (CT) showed low-density area in the right internal capsule. Systemic CT revealed a large mass in the right neck and multiple masses in the bilateral lung field, indicating lung metastases of thyroid cancer. Brain diffusion-weighted magnetic resonance imaging showed high-intensity area in the right internal capsule and the Diffusion-Weighted Imaging–Alberta Stroke Program Early CT score was 9 (Fig. 1A). In the fluid-attenuated inverted recovery image the lesion appeared as a high-intensity area. The right internal carotid artery (ICA) was not visualized with magnetic resonance angiography. On the basis of the diagnosis of acute cerebral infarction by the right ICA occlusion, endovascular recanalization was performed. A recombinant tissue plasminogen activator (rt-PA) was not administered considering the risk of bleeding due to thyroid cancer and multiple lung metastases. A 9-Fr Optimo balloon guiding catheter (Tokai Medical Products) was introduced into the right common carotid artery, and occlusion at the origin of the right ICA was confirmed by angiography (Fig. 1B). A REACT-71 aspiration catheter (Medtronic) was navigated to the occlusion site, and the embolus was aspirated. Several pieces of red thrombus were aspirated (Fig. 1C) and the proximal part was recanalized. Angiography revealed occlusion at the bifurcation of the right ICA. Thereafter, a Phenom-27 microcatheter (Medtronic) and aspiration catheter were guided to the middle cerebral artery (MCA) in a coaxial manner, and sandwich angiography showed a defect in contrast medium at the horizontal portion of the right MCA, indicating the existence of another embolus (Fig. 1D). A Solitaire stent retriever (6 × 40 mm; Medtronic) was deployed; however, flow restoration was not observed. The aspiration catheter was brought closer to the stent retriever, and both devices were retrieved by combined technique. A long string-form, white mucous embolus was removed (Fig. 1E), and the occlusion was recanalized completely (Fig. 1F). Pathological analysis of the embolus showed thyroid cancer under hematoxylin and eosin and vimentin staining (Fig. 2). Pulmonary invasion of the lung lesion was discovered on systemic contrast-enhanced CT, and it was suspected as the cause of the tumor embolism (Fig. 3). The carotid artery was dislocated due to primary thyroid cancer but not invaded.

FIG. 1.
FIG. 1.

A: Diffusion-weighted magnetic resonance imaging (MRI) shows early ischemic change in the right internal capsule. B: Right carotid angiography, anteroposterior view, shows complete occlusion of the ICA after bifurcation. C: The soft and fragile red embolus was removed using a REACT-71 aspiration catheter from the cervical ICA. D: A Phenom-27 microcatheter was navigated to the right M1 distal and a REACT-71 aspiration catheter was guided to C4; a contrast defect (arrow) was found in M1 proximal on sandwiched angiography, which indicates the existence of an embolus. E: The soft and mucous white embolus was removed using a Solitaire retriever from M1. F: A combined technique with the REACT-71 aspiration catheter and Solitaire retriever (6 × 40 mm) was performed, and complete recanalization was achieved.

FIG. 2.
FIG. 2.

A: The aspirated red embolus shows a thrombus component with a few tumor cells. Both the retrieved white embolus (B) and the cervical biopsy specimen of primary thyroid cancer (C) show spindle cells and mucinous ground. Hematoxylin and eosin (H&E) stain.

FIG. 3.
FIG. 3.

Contrast-enhanced CT. Thyroid cancer (*, A) excluded the trachea and carotid artery (arrow) but did not invade the right carotid artery. The lung metastases invaded the pulmonary veins, and the contrast defect (arrowhead, B) is confirmed.

Discussion

Observations

Endovascular treatment for acute cerebral artery occlusion has been evolving dramatically with the development of new devices. Pathological study of the retrieved thrombus rarely reveals tumor embolism. We reviewed cases of tumor embolism treated with endovascular methods that are listed in Table 1. Hoffmeier et al.2 reported that most cerebral tumor embolisms are caused by cardiac tumors. Among them, 70% were cardiac myxoma and 10% were cardiac metastasis. With regard to cardiovascular invasion, invasion to the pulmonary vein or left ventricle was reported3 and the majority of the primary lesions were lung or breast cancer. To the best of our knowledge, this is the first case of thyroid cancer embolism resulting in acute cerebral infarction and a long string-form embolus was removed. The primary lesion in this case was large; however, the carotid artery was intact. Contrast-enhanced CT showed pulmonary vein invasion of metastatic lung lesion, which seemed to have caused the tumor embolism. We finally diagnosed cerebral tumor embolism based on pathology. Therefore, it was important to examine the embolus pathologically.

TABLE 1.

Summary of case reports of tumor embolisms with mechanical thrombectomy

Authors & YearAge (yrs)GenderOcclusion SitePre-NIHSSDevicePost-TICI ScorePrimary Lesion
Bhatia et al., 20101262 FLt M119 Merci2a Lung metastasis of breast cancer
Tejada et al., 20141364 FRt M116 Solitaire3 Cardiac papillary fibroelastoma
Santos et al., 20141434 MLt M117 N/A2b Cardiac papillary fibroelastoma
Baek et al., 20141546 MLt ICAN/APenumbra3 Cardiac myxoma
Garcia-Ptacek et al., 20141645 N/ALt M127 Solitaire/Trevo/Wingspan0 Cardiac myxoma
34 N/ALt M126 Solitaire3 Cardiac myxoma
Ryu et al., 20151734 MRt M19 Merci3 Cardiac myxoma
Vega et al., 20151811 MRt M116 Trevo/Penumbra3 Cardiac myxoma
Biraschi et al., 20161975 MLt M118 Penumbra3 Cardiac papillary fibroelastoma
Chung et al., 2016204 MLt M116 Solitaire3 Cardiac myxoma
Zander et al., 20162146 FLt M116 Solitaire3 Cardiac myxoma
58 MLt M224 Solitaire3 Pulmonary adenocarcinoma
Pop et al., 20182256 MBA/ICAN/ASolitaire3BA/2bICAIntrathoracic sarcoma
Abe et al., 20192379 MBA40 Penumbra3 Cardiac papillary fibroelastoma
Goddard et al., 20192480 MBA19 Penumbra2c Pulmonary neuroendocrine cancer
Tsurusaki et al., 2019772 MLt ICA13 Solitaire/Trevo/Penumbra3 Pulmonary squamous cell carcinoma
Oyama et al., 2019634 MLt ICA17 Solitaire/Penumbra2b Pulmonary mucoepidermoid carcinoma
Yoshikawa et al., 20202566 MRt M114 Trevo3 Pleomorphic pulmonary carcinoma
Moriyama et al., 20212664 MRt M210 Trevo/Penumbra2b Pulmonary squamous cell carcinoma
Fujiwara et al., 20222774 MLt M222 Trevo2b Pulmonary squamous cell carcinoma
Present case57 MRt ICA M111 Solitaire/REACT3 Thyroid carcinoma

BA = basilar artery; N/A = not available; NIHSS = National Institutes of Health Stroke Scale Score; TICI = thrombolysis in cerebral infarction.

With regard to recanalization therapy for the acute cerebral artery occlusion induced by tumor embolism, Ikeda et al.4 reported the effectiveness of intravenous rt-PA therapy for the thrombus component of the cardiac myxoma embolism; however, it was less effective for the tumor component. In this case, rt-PA was not administered considering a risk of hemorrhagic complications. However, the embolus (Fig. 1C) was mainly a red thrombus, which was formed secondary to the tumor embolus (Fig. 4); hence, rt-PA could have been effective treatment.5 Instead, endovascular treatment was used emergently. The tumor embolism is usually soft and fragile. Therefore, retrieval with a stent retriever alone may fail complete removal. Oyama et al.6 recommended the use of an aspiration catheter to prevent distal migration of the embolus. On the contrary, Tsurusaki et al.7 reported that the push-and-fluff technique using a Trevo Pro Vue Retriever (Stryker) was effective for a hard embolus. However, preoperatively, it is difficult to identify the cause of embolism as tumor embolus and the softness of the embolus. As shown in Table 1, a stent retriever was mainly used in the previous report and both stent retriever and aspiration catheter were effective for collecting tumor embolus. In this case, both origin and bifurcation of the right ICA were occluded, so-called “tandem lesion.” The proximal part may have coagulated following blood stagnation and red thrombus was aspirated. The distal part was tumor embolus and retrieved successfully using a combination of stent retriever and aspiration catheter. The ASTER2 trial8 reported the superiority of a combined technique on first-pass effect and that it may be more effective in removing tumor embolus. Reviewing previous pathological studies of retrieved thrombi, Douglas et al.9 reported that patients with platelet-rich clots have poorer revascularization outcomes. The analysis of thrombus fragments retrieved in each pass revealed that the red blood cell contents of thrombus fragments retrieved in passes 1 and 2 were significantly higher than those retrieved in passes 3 to 6.10 Occasionally, a fragment of atheromatous plaque is identified in the occlusive thrombi retrieved from cerebral arteries, indicating an atherothrombotic etiology.11 The retrieved clot is not always sent for pathology but doing so facilitated a critical diagnosis.

FIG. 4.
FIG. 4.

A: H&E stain: the red thrombus is mainly composed of red blood cells and fibrin. B: CD42b stain: platelets were stained. However, platelets are only partially stained, indicating that it contains platelets, although platelets are not dominant. Thus, it was not platelet thrombosis. C: Phosphotungstic acid-hematoxylin stain: fibrin is stained blue. Thus, it was a fibrin-rich thrombus. Original magnification ×100 (A–C).

Lessons

A case of cerebral tumor embolism of thyroid cancer is reported. Lung metastasis invading the pulmonary vein may have been the cause of tumor embolism. Mechanical thrombectomy using a combination of stent retriever and aspiration catheter is effective in the removal of tumor embolus, and pathological evaluation of the embolus is important.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Fujiwara, Hayashi, Yamasaki, Uchimura, Kambara, Nagai. Acquisition of data: Fujiwara, Shibata, Yamasaki, Yamamoto, Uchimura, Nakagawa, Kambara, Nagai. Analysis and interpretation of data: Fujiwara, Yamasaki, Uchimura, Nakagawa. Drafting of the article: Fujiwara, Hayashi, Uchimura, Nagai. Critically revising the article: Fujiwara, Nagai. Reviewed submitted version of the manuscript: Uchimura. Approved the final version of the manuscript on behalf of all authors: Fujiwara. Administrative/technical/material support: Furuta, Uchimura, Nagai, Akiyama. Study supervision: Hayashi, Nagai, Akiyama.

References

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  • FIG. 1.

    A: Diffusion-weighted magnetic resonance imaging (MRI) shows early ischemic change in the right internal capsule. B: Right carotid angiography, anteroposterior view, shows complete occlusion of the ICA after bifurcation. C: The soft and fragile red embolus was removed using a REACT-71 aspiration catheter from the cervical ICA. D: A Phenom-27 microcatheter was navigated to the right M1 distal and a REACT-71 aspiration catheter was guided to C4; a contrast defect (arrow) was found in M1 proximal on sandwiched angiography, which indicates the existence of an embolus. E: The soft and mucous white embolus was removed using a Solitaire retriever from M1. F: A combined technique with the REACT-71 aspiration catheter and Solitaire retriever (6 × 40 mm) was performed, and complete recanalization was achieved.

  • FIG. 2.

    A: The aspirated red embolus shows a thrombus component with a few tumor cells. Both the retrieved white embolus (B) and the cervical biopsy specimen of primary thyroid cancer (C) show spindle cells and mucinous ground. Hematoxylin and eosin (H&E) stain.

  • FIG. 3.

    Contrast-enhanced CT. Thyroid cancer (*, A) excluded the trachea and carotid artery (arrow) but did not invade the right carotid artery. The lung metastases invaded the pulmonary veins, and the contrast defect (arrowhead, B) is confirmed.

  • FIG. 4.

    A: H&E stain: the red thrombus is mainly composed of red blood cells and fibrin. B: CD42b stain: platelets were stained. However, platelets are only partially stained, indicating that it contains platelets, although platelets are not dominant. Thus, it was not platelet thrombosis. C: Phosphotungstic acid-hematoxylin stain: fibrin is stained blue. Thus, it was a fibrin-rich thrombus. Original magnification ×100 (A–C).

  • 1

    Graus F, Rogers LR, Posner JB. Cerebrovascular complications in patients with cancer. Medicine (Baltimore). 1985;64(1):1635.

  • 2

    Hoffmeier A, Sindermann JR, Scheld HH, Martens S. Cardiac tumors—diagnosis and surgical treatment. Dtsch Arztebl Int. 2014;111(12):205211.

  • 3

    Kawasaki Y, Sugino K, Nambu J, Nishihara M, Misumi T, Shimamoto F. A case of anaplastic transformation of follicular thyroid carcinoma with metastasis to left ventricle. Official J Jpn Asso Endocr Surg Jpn Soc Thyroid Surg. 2019;36:182188.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Ikeda T, Oomura M, Sato C, Anan C, Yamada K, Kamimoto K. [Cerebral infarction due to cardiac myxoma developed with the loss of consciousness immediately after defecation—a case report]. Rinsho Shinkeigaku. 2016;56(5):328333.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Jolugbo P, Ariëns RAS. Thrombus composition and efficacy of thrombolysis and thrombectomy in acute ischaemic stroke. Stroke. 2021;52(3):11311142.

  • 6

    Oyama T, Asai T, Miyazawa T, et al. A case of cerebral tumor embolism from extracardiac lung cancer treated by mechanical thrombectomy. NMC Case Rep J. 2020;7(3):101105.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Tsurusaki Y, Takahara K, Koga N, Amano T, Haga S, Arihiro S. A case of mechanical reperfusion therapy for cerebral infarction induced by tumor embolism from lung cancer. J Neuroendovasc Ther. 2019;13:342347.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Lapergue B, Blanc R, Costalat V, et al. Effect of thrombectomy with combined contact aspiration and stent retriever vs stent retriever alone on revascularization in patients with acute ischemic stroke and large vessel occlusion: the ASTER2 randomized clinical trial. JAMA. 2021;326(12):11581169.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Douglas A, Fitzgerald S, Mereuta OM, et al. Platelet-rich emboli are associated with von Willebrand factor levels and have poorer revascularization outcomes. J Neurointerv Surg. 2020;12(6):557562.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Duffy S, McCarthy R, Farrell M, et al. Per-pass analysis of thrombus composition in patients with acute ischemic stroke undergoing mechanical thrombectomy. Stroke. 2019;50(5):11561163.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Hashimoto T, Hayakawa M, Funatsu N, et al. Histopathologic analysis of retrieved thrombi associated with successful reperfusion after acute stroke thrombectomy. Stroke. 2016;47(12):30353037.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    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;112(3):572574.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Tejada J, Galiana A, Balboa O, et al. Mechanical endovascular procedure for the treatment of acute ischemic stroke caused by total detachment of a papillary fibroelastoma. J Neurointerv Surg. 2014;6(6):e37.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Santos AF, Pinho J, Ramos V, Pardal J, Rocha J, Ferreira C. Stroke and cardiac papillary fibroelastoma: mechanical thrombectomy after thrombolytic therapy. J Stroke Cerebrovasc Dis. 2014;23(5):12621264.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    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(9):e417e419.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Garcia-Ptacek S, Matias-Guiu JA, Valencia-Sánchez C, et al. Mechanical endovascular treatment of acute stroke due to cardiac myxoma. J Neurointerv Surg. 2014;6(1):e1.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Ryu B, Ishikawa T, Sato S, 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(2):5356.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

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