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Images in Neurology |

Forced-Suction Thrombectomy of an Arterial Tumor Embolism Due to Metastatic Melanoma

Chan Soon Kim, MD; Hye-Ra Jung, MD; Kyung-Hee Cho, MD; Hyuk Won Chang, MD; Sung-Il Sohn, MD; Tae Hyun Choi, MD, PhD; Yong Won Cho, MD, PhD; Chul-Ho Sohn, MD, PhD
Arch Neurol. 2012;69(2):272. doi:10.1001/archneurol.2011.982.
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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).

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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).

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