□ CASE REPORT □

An Infrequent Type of Stroke with an Unusual Cause
and Successful Therapy: Basilar Artery Occlusion Caused
by a Cardiac Papillary Fibroelastoma Recanalized
12 Hours after Onset
Josip Ljevak 1, Antonija Mišmaš 1, Antonela Bazina 1, Vesna Matijevi!1, Domagoj Alvir 1,
Svjetlana Šupe 1, Snježana Juren Meaški 1, David Ozreti!2,
Zdravka Poljakovi!1,3 and Mario Habek 1,3

Abstract
We herein report the case of a 32-year-old woman with sudden onset ataxia, limb dysmetria and somnolence. Emergency radiological findings showed bilateral cerebellar and thalamic infarctions as a result of a
basilar artery occlusion. The patient was treated with intra-arterial (IA) and mechanical thrombolysis 12
hours after symptom onset and showed an excellent recovery. A diagnostic workup revealed a tumor mass on
the mitral valve that was surgically removed, while a histological analysis confirmed a diagnosis of cardiac
papillary fibroelastoma.
Key words: basilar artery occlusion, intra-arterial thrombolysis, mechanical thrombolysis, cardiac papillary
fibroelastoma
(Intern Med 52: 277-279, 2013)
(DOI: 10.2169/internalmedicine.52.8739)

Introduction
Acute basilar artery occlusion (BAO) is, in the majority
of patients, a devastating neurological condition associated
with a high risk of long-term disability and death. Despite
this well-known fact and the availability of several different
treatment options, there are still no definitive treatment
guidelines. We herein present the case of a young patient diagnosed with an acute stroke caused by BAO who was successfully treated with a combination of intra-arterial and mechanical thrombolysis performed with a substantial time delay. A further workup revealed that this incident was the
first presentation of a rare benign cardiac tumor.

Case Report
A 32-year-old woman was brought to our emergency de-

partment following the sudden onset of disturbed consciousness, vertigo with instability, nausea and vomiting. An initial
clinical examination revealed somnolence, dysarthria, horizontal left-beating nystagmus, a positive Romberg sign and
bilateral limb ataxia. Urgent brain magnetic resonance imaging (MRI) showed multiple ischemic lesions in both cerebellar hemispheres and both thalami without signs of intracranial hemorrhage, while magnetic resonance angiography
(MRA) demonstrated occlusion of the distal third of the
basilar artery (Fig. 1). Transthoracic echocardiography
(TTE) performed in the Emergency Department (ED)
showed only minimal mitral insufficiency with no visible tumor masses. Immediate cerebral digital subtraction angiography (DSA) confirmed the presence of an acute BAO distal
to the origin of the anterior inferior cerebellar arteries, with
sustained circulation through the posterior cerebral arteries
without any signs of vertebral artery dissection (Fig. 2). A
microcatheter (Headway-17, Microvention) was then navi-

１

Department of Neurology, University Hospital Center Zagreb, Croatia, ２Department of Radiology, University Hospital Center Zagreb, Croatia
and ３School of Medicine, University of Zagreb, Croatia
Received for publication August 4, 2012; Accepted for publication October 3, 2012
Correspondence to Dr. Mario Habek, mhabek@mef.hr

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DOI: 10.2169/internalmedicine.52.8739

Figure 2.
DSA.
Figure 1. Prethrombolysis dwi (b=1,000 mm2/s) showing bilateral lesions in the cerebellum and thalami.

Figure 3.
bolysis.

ited only mild right hand ataxia and mild dysarthria. The
laboratory findings, including extensive hematology, immunology and coagulation tests, showed only mild anemia and
a urinary tract infection, which was treated with antibiotics,
and were otherwise unremarkable. The carotid and vertebral
artery ultrasonography findings were normal, as were the results of a 24-hour electrocardiogram. A transesophageal
echocardiogram (TEE) showed a small tumor mass adherent
to the anterior leaflet of the mitral valve. After achieving an
excellent neurological recovery, the patient underwent surgical resection of the heart tumor. A pathologic analysis confirmed the diagnosis of papillary fibroelastoma. On a
follow-up examination conducted after six months, the patient was found to have no neurologic deficits and the cerebral MRA findings were completely normal.

Discussion

Vertebral artery recanalization after IA throm-

gated through the thrombus, and the patency of both posterior cerebral arteries was assessed. The microcatheter was
then withdrawn, and an infusion of r-tPA in front and inside
of the thrombus was started. After the administration of 50
mg of r-tPA, control angiography showed recanalization of
the basilar artery with residual stenosis (up to 50%) at the
site of the thrombus and persistent occlusion of the left posterior cerebral artery (PCA). The residual clot in the left
PCA was then mechanically disrupted using microwire
(Agility-14, Codman) manipulation. Following this maneuver, appropriate distal filling was achieved (Fig. 3). Additionally, 4 mg of r-tPA were administered at the site of the
basilar artery stenosis without evident effects. The procedure
was terminated when a full dose of r-tPA was reached. Further mechanical fragmentation was aborted due to the risk
of perforator occlusion. Follow-up brain MRI performed after nine days showed bilateral ischemic lesions in the pons,
cerebellum and thalami, while cerebral MRA continued to
show basilar artery stenosis. At that time, the patient exhib-

Distal vertebral artery occlusion as seen on initial

We herein present the case of a 32-year-old woman with
a basilar artery occlusion that was successfully treated with
combined IA and mechanical thrombolysis 12 hours after
the onset of the initial symptoms. A diagnostic workup revealed a rare benign cardiac tumor as the source of the cerebral embolus. Compared to anterior circulation strokes, basilar artery occlusions occur less frequently; however, without
recanalization, BAOs are associated with an extremely high
mortality rate. Current treatment guidelines restrict the use
of IA thrombolysis to six hours from the onset of symptoms
caused by occlusion of the MCA, with a number of reported
cases of successful treatment administered over prolonged
time periods after the initial onset of symptoms (1, 2). Randomized controlled data on the treatment of acute BAO are
lacking and focus primarily on IV or IA thrombolysis.
Available studies on mechanical thrombolysis show different
results, with some suggesting the superiority of mechanical
thrombolysis as a separate treatment (3) and others showing
no statistically significant superiority of any treatment strategy (4). Considering the poor prognoses and outcomes of
patients with basilar artery occlusions, there is no strict time

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DOI: 10.2169/internalmedicine.52.8739

restriction for the use of local thrombolytic therapy to treat
BAOs.
In this particular case, the patient presented to the ED approximately nine hours after the onset of symptoms because
her initial symptoms (nausea and vomiting) were regarded
as symptoms of an infectious gastric disturbance, thus being
ineligible for IV thrombolysis. Given the severity of her
neurological deficits, the radiological findings of multiple
infarctions and BAO, local thrombolysis was performed despite the fact that 12 hours had passed after the onset of
symptoms. The patient’s clinical recovery was excellent.
The source of the cerebral embolus, cardiac papillary fibroelastoma (PFE), is the third most common type of heart
tumor and occurs primarily in persons over the age of 50
with no sex preferences. PFEs are typically asymptomatic,
although they remain a possible source of cerebral emboli,
either from the tumor itself or from fibrin thrombi attached
to its surface (5, 6). In this case, r-TPA therapy achieved
partial recanalization of the basilar artery; therefore, the mechanical clot disruption that followed was necessary to
achieve additional thrombolytic effects. Thrombectomy was
not performed; hence, further pathohistological analyses of
the embolus were not possible. Based on the limited effects
of the locally applied full dose of r-TPA and the success of
mechanical thrombolysis, we can speculate that the embolus
may have been composed of both fibrin and tumor tissue, or
less probably, fibrin only.
There are no randomized controlled studies on the application of thrombolytic agents in patients with cardiac tumorinduced strokes. To the best of our knowledge, the literature
contains only two reports of thrombolytic agents being successfully used to treat PFE-associated strokes: one case reported successful intravenous (IV) thrombolysis (6) and one
case reported successful intra-arterial thrombolysis (7). In
both cases, the strokes were in the anterior circulation. In
addition, we found only one case involving the use of mechanical thrombolysis in the treatment of a stroke caused by
a cardiac myxoma embolus (8).
In conclusion, this is the first case in which the initial and
only clinical presentation of a rare cardiac tumor was a severe posterior circulation stroke that was successfully treated
with delayed IA thrombolysis combined with mechanical
clot disruption. Adding to this rare etiology, we believe that
the most aggressive treatment of this form of stroke was jus-

tified, despite the risks and substantial time delay.
The authors state that they have no Conflict of Interest (COI).
Authors’ contributions
Study concept and design: Juren, Ozreti!, Poljakovi!, Habek.
Acquisition of data: Ljevak, Mišmaš, Bazina, Matijevi!, Alvir,
Juren, Ozreti!, Poljakovi!, Habek. Analysis and interpretation of
data: Ljevak, Mišmaš, Bazina, Matijevi!, Alvir, Juren, Ozreti!,
Poljakovi!, Habek. Drafting of the manuscript: Ljevak, Habek.
Critical revision of the manuscript for important intellectual content: Ljevak, Mišmaš, Bazina, Matijevi!, Alvir, Juren, Ozreti!,
Poljakovi!, Habek. Administrative, technical, and material support: Ljevak, Mišmaš, Bazina, Matijevi!, Alvir, Juren, Ozreti!,
Poljakovi!, Habek.

References
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Ⓒ 2013 The Japanese Society of Internal Medicine
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