A 49-year-old woman presented with 2 weeks of cough and fevers and 1 week of right-sided weakness and difficulty speaking. Examination was notable for tachycardia, distant heart sounds, jugular venous distention, pulsus paradoxicus, and Janeway lesions. Neurologic examination revealed global aphasia, right homonymous hemianopsia, and a right hemiparesis. Laboratory examination was remarkable for a troponin level of 0.45 ng/mL (to convert to micrograms per liter, multiply by 1) and an erythrocyte sedimentation rate of 83 mm/h. Head computed tomography demonstrated an acute left middle cerebral artery territory infarction (Figure, A). Transthoracic echocardiogram showed a pericardial effusion, cardiac tamponade, and 3 large mobile echodensities in the left ventricle (Figure, B). Chest computed tomography demonstrated a large mediastinal mass encasing the great vessels and bronchi, innumerable pulmonary nodules, and a segmental pulmonary embolus.
Imaging and histologic findings in a patient with multifocal stroke from tumor emboli. A, Head computed tomography demonstrating a left frontal lobe hypodensity consistent with middle cerebral artery territory infarction. B, Transthoracic echocardiogram with apical 3-chamber view showing 2 large mobile echodensities attached to the septum and inferolateral wall of the left ventricle (V). C, Frontal lobe arteriole occluded by moderately differentiated squamous cell carcinoma. Recent infarction is present surrounding the embolus, with disintegration, vacuolization, and pyknosis of neurons (hematoxylin-eosin, original magnification ×20). D, Tumor embolus of squamous cell carcinoma occluding a cerebellar vessel. Small areas of infarction surround the embolus, with proliferation of capillaries and macrophages (hematoxylin-eosin, original magnification ×40).
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