A 22-year-old woman who had a speech disturbance for 20 minutes sought evaluation at our hospital (she had a National Institute of Health Stroke Scale score of 4). She had been diagnosed with a malignant melanoma in the left calf with multiple metastases to the brain, both upper arms, chest walls, heart, and right axillary, right supraclavicular, and right renal hilar lymph nodes (Figure, A), and she had previously undergone chemotherapy and whole-brain radiotherapy. However, her functional status was good prior to the stroke. Results from magnetic resonance imaging and angiography according to the stroke protocol showed occlusion of the left proximal middle cerebral artery. Because the 2 brain metastases were large and hemorrhagic, intravenous tissue plasminogen activator was not administered (Figure, B, and eFigure). Rather, she was transported to the angiography suite, and forced-suction thrombectomy was attempted without intra-arterial thrombolysis for fear of intracerebral hemorrhage. After several attempts with the technique, complete recanalization of the left middle cerebral artery was achieved within 30 minutes (Figure, C and D). After the procedure, her Stroke Scale score was 1 (24 hours after onset of symptoms). A pathologic examination of the clot revealed a metastasis from the malignant melanoma (Figure, E).
Figure. Radiologic and pathologic findings. A, Positron emission tomography with fludeoxyglucose F18 reveals multiple metastases in both upper arms (black arrows), chest walls (white arrows), heart (asterisk), and right axillary, right supraclavicular, and right renal hilar lymph nodes (black arrowheads). B, Axial gradient-echo sequence of brain magnetic resonance imaging scan shows large hemorrhagic brain metastasis in the right frontal lobe (the other metastasis in the right occipital lobe is shown in our eFigure). C, Initial conventional angiography reveals occlusion of the distal M1 portion of the left middle cerebral artery (MCA). D, After several trials of forced-suction thrombectomy, there was complete recanalization of the left MCA to the distal branch. E, The metastatic malignant melanoma clot from the left MCA consists of large pleomorphic cells with a high nuclear-to-cytoplasmic ratio. Immuohistochemistry of the clot shows tumor cells immunostained by S-100 (original magnification ×400).
Thank you for submitting a comment on this article. It will be reviewed by JAMA Neurology editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 1
Customize your page view by dragging & repositioning the boxes below.
More Listings atJAMACareerCenter.com >
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.