© 2004 by European Society of Cardiology
Copyright © 2004, The European Society of Cardiology
Ultrasonography in embolic stroke: the complementary role of transthoracic and transesophageal echocardiography in a case of systemic embolism by tumor invasion of the pulmonary veins in a patient with unknown malignancy involving the lung
aDivision of Cardiology, Santa Maria di Loreto Hospital, Naples, Italy
bDivision of Neurology, Santa Maria di Loreto Hospital, Naples, Italy
Received 21 July 2003; received in revised form 22 December 2003; accepted after revision 5 January 2004.
luigi.ascione20{at}tin.it
* Corresponding author. Viale dei Pini, 4 Portici (NA) 80055, Italy. Tel./fax: +39-081-7755064.
 |
Abstract |
|---|
 Top Abstract 1 Introduction2 Case report3 DiscussionReferences |
|---|
Two-dimensional transthoracic echocardiography is commonly performed to detect a possible cardiac source of systemic embolism and it has been the mainstay of detection and diagnosis of cardiac masses. The transesophageal approach has enhanced the ability to detect cardiac sources of embolism by allowing a better visualization of posterior cardiac structures such as the left atrium with left atrial appendage, pulmonary veins and thoracic aorta and by providing higher resolution images to improve assessment of the presence and extent of cardiac masses. In this case report, echocardiography, using both transthoracic and transesophageal approach, allowed to detect a neoplastic mass arising from the upper left pulmonary vein in a patient presented with a transient ischemic attack. Further investigations showed a malignancy involving the lung. To our knowledge, this is the first reported case in which a cerebral embolic episode represents the clinical onset of a lung cancer, pointing out the importance of echocardiography in all cases of undetermined cerebral ischemic attack.
Keywords: Echocardiography; Cardiogenic embolism; Pulmonary veins; Pulmonary malignancy
|
1 Introduction |
|---|
|
TopAbstract1 Introduction2 Case report3 DiscussionReferences |
|---|
A cardiogenic embolism is responsible for ischemic stroke in 15–30% of cases. The neoplastic nature of embolus is unusual and becomes rare enough excluding systemic tumor emboli caused by left atrial myxomas.1 In fact most nonatherosclerotic strokes and peripheral arterial occlusions, in patients with malignancies, are due to a hypercoaguable state or embolization from valvular vegetations caused by a concurrent endocarditis.2,3
We report a case of tumor embolization in a patient presenting with a stroke. Two-dimensional transthoracic echocardiography (TTE) visualized a pedunculated and mobile mass in the left atrium and then transesophageal echocardiography (TEE) showed a mass arising from the left upper pulmonary vein, free-floating in the left atrium, giving rise to clinical suspicion of a malignancy involving the lung as a possible source of embolism.
|
2 Case report |
|---|
|
TopAbstract1 Introduction2 Case report3 DiscussionReferences |
|---|
A 53-year-old man, with a history of diabetes well controlled with oral hypoglycemic agents, presented to the emergency room with a transient ischemic attack manifesting as right hemiparesis; he reported a transient left hemiparesis a month ago but a medical consultation was not requested at that time. A magnetic resonance imaging scan revealed ischemic lesions in the right external capsule and in the left frontal and parietal white substance. A vascular ultrasound examination revealed nonsignificant stenosis of both the right and left internal carotid arteries (35% and 25%, respectively). In addition blood tests did not show a hypercoaguable state or other coagulation disorders.
A two-dimensional TTE was performed to detect a possible cardiac embolic source. Parasternal long axis and four-chamber apical views visualized a filiform, pedunculated and mobile mass in the left atrium (Fig. 1a and b). To better assess the nature of this lesion, a multiplane transesophageal echocardiographic study was performed. Midesophageal 50° view showed a large and pedunculated mass arising from the upper left pulmonary vein, free-floating in the left atrium (Fig. 2a); the lesion, of variable and heterogeneous texture, was suggestive of a neoplastic mass. Colour-flow imaging of upper left pulmonary vein revealed a turbulent flow like a pulmonary vein obstruction (Fig. 2b).
|
|
Further investigations were performed in search of starting localization of the neoplastic mass. A chest X-ray film and a computed tomographic (CT) scan revealed a large mass (90 x 60 mm), located in the posterior portion of the upper lobe of the left lung. Cytologic examination of the specimen, taken through a CT-guided fine-needle aspiration biopsy (FNAB), was consistent with an undifferentiated adenocarcinoma.
The dramatical evolution of the clinical course did not allow a further staging and a therapeutic evaluation. In fact, in a week, the patient progressively presented dysphasia, ataxia, aphasia, dysphagia and, finally, respiratory arrest, presumably for subintrant cerebral embolic events. He subsequently died. No autopsy was performed.
|
3 Discussion |
|---|
|
TopAbstract1 Introduction2 Case report3 DiscussionReferences |
|---|
An advanced pulmonary tumor can have access to the arterial system through the pulmonary veins. Previous reports have documented intracardiac extension of pulmonary malignancies with the consequent systemic embolism. The sites of tumor emboli most frequently reported are the aortic bifurcation or femoral vessels (50%) and the cerebral circulation (30%).4,5 In the majority of cases tumor embolization occurs during, or shortly after, pulmonary resection.6 Gandhi et al.3 described two cases of spontaneous systemic tumor embolization caused by tumor invasion of the pulmonary vein, in which TEE was able to identify the source of the embolus. These are the only two cases of spontaneous embolism described in literature.
All cases mentioned above, spontaneous or associated to pulmonary resection, concern patients with known pulmonary malignancy, in which the embolism is a complication of an evident clinical picture. To our knowledge, our reported case is the first one in which the cerebral cardioembolic episode represents the clinical onset of the disease. In fact, the patient did not present any symptom or sign suggestive of a pulmonary malignancy. In this context, echocardiogram becomes important as it can reveal the cardiac source of embolism, training for further enquiries in search of the primary disease.
Echocardiography is recommended in all young patients (less than 45 years) with neurological events and in old ones (more than 45 years) without evidence of cerebrovascular disease;7 moreover, it is fairly recommended, in the latter group, when there is clinical evidence of cardiac disease8 and when the events occur in multiple cerebrovascular territories.7 TTE is well suited to detect some potential cardioembolic sources (mitral stenosis, dilated cardiomyopathy, left ventricular aneurysm with thrombus, mitral valve prolapse, vegetation), however, TEE is the technique of choice in the detection of left atrial and appendage thrombus, spontaneous contrast, atrial septal aneurysm, patent foramen ovale and aortic atheroma.7
Tumor invasion of the pulmonary veins, even if rare enough, must be considered among the possible causes of systemic embolism, therefore a meticulous examination of all four pulmonary veins is advisable. In adult population, TTE allows the visualization of only two pulmonary veins in 71% of the patients;9 TEE increases the success rate for the visualization of pulmonary veins to 100% for superior veins and the right inferior one while the left inferior vein was visualized in 87% of the patients.10 For these reasons TEE is well suited to visualize pulmonary veins and a multiplane transesophageal study, that allows a better visualization of all pulmonary veins when compared with monoplane and biplane study, should be performed.11
The presence of an intracardiac mass can represent, in addition to a thrombus, a primary cardiac tumor or a metastatic lesion. In this case report, the presence, in the left atrium, of a mobile mass arising from the left upper pulmonary vein and the absence of other abnormalities at echocardiographic examination suggested the diagnosis of neoplastic invasion of the left upper pulmonary vein; however, these echocardiographic features may not always be diagnostic and in this context contrast echocardiography may be used to evaluate the vascularity of a cardiac mass helping to differentiate malignant tumors from other avascular masses.12
In conclusion this case report reaffirms the importance of echocardiography as useful diagnostic means to detect cardiac embolic sources also in patients without a pre-existing cardiac disease, and underscores that a TEE should always be performed when the cause of cerebral ischemic attack is unknown.
|
References |
|---|
|
TopAbstract1 Introduction2 Case report3 DiscussionReferences |
|---|
- O'Neill B.P, Dinapoli R.P, Okazaki H. Cerebral infarction as a result of tumor emboli. Cancer (1987 July 1) 60(1):90–95.[CrossRef]
- Lefkovitz N.M, Roessmann U, Kori S.H. Major cerebral infarction from tumor embolus. Stroke (1986) 17:555–557.
[Abstract/Free Full Text] - Gandhi A.K, Pearson A.C, Orsinelli D.A. Tumor invasion of the pulmonary veins: a unique source of systemic embolism detected by transesophageal echocardiography. J Am Soc Echocardiogr (1995 Jan–Feb) 8(1):97–99.[CrossRef][Medline]
- Isada L.R, Salcedo E.E, Homer D.A, Cohen G.I, Rice T.W. Intraoperative transesophageal echocardiographic localization of tumor embolus during pneumonectomy. J Am Soc Echocardiogr (1992 Sep–Oct) 5(5):551–554.[Medline]
- Whyte R.I, Starkey T.D, Orringer M.B. Tumor emboli from lung neoplasms involving the pulmonary vein. J Thorac Cardiovasc Surg (1992) 104:421–425.[Abstract]
- Mansour K.A, Malone C.E, Craver J.M. Left atrial tumor embolization during pulmonary resection: review of literature and report of two cases. Ann Thorac Surg (1988) 46:455–456.[Abstract]
- Cheitlin M.D, Armstrong W.F, Aurigemma G.P, Beller G.A, Bierman I, Davis J.L, et al. ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography. J Am Soc Echocardiogr (2003 Oct) 16(10):1091–1110.[Web of Science][Medline]
- Kapral M.K, Silver F.L. Preventive health care, 1999 update: 2. Echocardiography for the detection of a cardiac source of embolus in patients with stroke. Canadian Task Force on Preventive Health Care. CMAJ (1999 Oct 19) 161(8):989–996.
- Bansal R.C, Tajik A.J, Seward J.B, Offard K.P. Feasibility of detailed two-dimensional echocardiographic examination in adults. Mayo Clin Proc (1980) 55:291–308.[Web of Science][Medline]
- Orihashi K, Goldiner P.L, Oka Y. Intraoperative assessment of pulmonary vein flow. Echocardiography (1990) 7:261–271.[Medline]
- Warner J.G Jr., Nomeir A.M, Salim M, Kitzman D.W. A prospective, randomized, blinded comparison of multiplane and biplane transesophageal echocardiographic techniques. J Am Soc Echocardiogr (1996 Nov–Dec) 9(6):865–873.[CrossRef][Medline]
- Lepper W, Shivalkar B, Rinkevich D, Belcik T, Wei K. Assessment of the vascularity of a left ventricular mass using myocardial contrast echocardiography. J Am Soc Echocardiogr (2002 Nov) 15(11):1419–1422.[CrossRef][Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  B. B. Navi, K. Kawaguchi, I. Hriljac, E. Lavi, L. M. DeAngelis, and D. G. Jamieson Multifocal Stroke From Tumor Emboli Arch Neurol, September 1, 2009; 66(9): 1174 - 1175. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||