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Case Studies

Histology of Thrombectomy Specimen Reveals Cardiac Tumor
Embolus in Cryptogenic Young Stroke
Kizhakkaniyakath Abdu Salam, MD, DM,*
Mohammed Rafeeque, MD, DMRD, PDCC,† Hisham Hashim, MBBS,*
Neena Mampilly, MD,‡ and Mohan Leslie Noone, MD, DM*

A 25-year-old woman presented with acute onset of right hemiplegia and global
aphasia with National Institutes of Health Stroke Scale score of 19. Computed
tomography angiography demonstrated occlusion of the left proximal middle cerebral artery. She was thrombolysed with intravenous recombinant tissue plasminogen
activator (0.6 mg/kg) within 3 hours of onset of symptoms and was taken up
for mechanical thrombectomy. The retrieved specimen appeared pale white and
soft; histopathologic examination revealed a papillary neoplasm composed of papillae with hyalinized cores lined by endothelium, consistent with papillary
fibroelastoma of cardiac origin. Transesophageal echocardiography showed no abnormalities, which can be explained by complete embolization of the mass into
the cerebral circulation. On follow-up after 5 months, the patient recovered with
only minimal aphasia and no cardiac symptoms. Our experience with this case
highlights the importance of histopathologic examination of the mechanical thrombectomy specimen, as it provided the only clue to the etiology of stroke. Key
Words: Stroke in the young—cardiac tumor—mechanical thrombectomy—papillary
fibroelastoma—all stroke.
© 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Case Report
A 25-year-old woman presented with acute onset of
right hemiplegia and global aphasia within 2 hours of
onset. She had no history of hypertension, diabetes
From the *Department of Neurology; †Department of Interventional
Radiology, Baby Memorial Hospital, Kozhikode, Kerala, India; and
‡Department of Pathology, Baby Memorial Hospital, Kozhikode, Kerala,
India.
Received September 28, 2017; revision received October 27, 2017;
accepted November 11, 2017.
Address correspondence to Mohan Leslie Noone, MD, DM,
Department of Neurology, Baby Memorial Hospital, Kozhikode, 673004
Kerala, India. E-mail: mln@fastmail.com.
1052-3057/$ - see front matter
© 2017 National Stroke Association. Published by Elsevier Inc. All
rights reserved.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.11.015

mellitus, or family history of stroke. The National
Institutes of Health Stroke Scale (NIHSS) score was 19.
She had no symptoms of cardiac illness, and the
clinical cardiovascular examination was unremarkable.
Unenhanced computed tomography (CT) scan of the
brain was normal (Alberta Stroke Program Early CT
score—ASPECTS 10), and CT angiography demonstrated occlusion of the left proximal middle cerebral
artery (M1). She was started on intravenous recombinant tissue plasminogen activator (0.6 mg/kg) (Alteplase,
Boehringer-Ingelheim, Ingelheim, Germany), within 3
hours of onset of symptoms and taken up for mechanical thrombectomy with the Solitaire FR Revascularization
Device (Covidien/ev3, Dublin, Ireland) (4 × 20 mm).
The occluded left M1 was recanalized in a single pass
(Fig 1). The procedure was completed within 5 hours of
onset of symptoms. The retrieved specimen appeared

Journal of Stroke and Cerebrovascular Diseases, Vol. ■■, No. ■■ (■■), 2017: pp ■■–■■

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K.A. SALAM ET AL.

Figure 1. (A) Computed tomography angiography showing occlusion of the proximal segment of
the left middle cerebral artery. (B) Postprocedural
revascularization. (C) Thrombectomy specimen. (D)
Histopathology showing papillary fibroelastoma of
cardiac origin.

to be a pale, white soft material and was sent for
histopathologic examination.
The patient improved well with NIHSS score of 10 after
24 hours and was discharged on day 8, with recovering
global aphasia and minimal right-sided weakness. On discharge, NIHSS score was 8 and modified Rankin scale
(mRS) score was 2.
Electrocardiography and transesophageal echocardiography showed no abnormalities. Antinuclear and
anticardiolipin antibodies were negative. Histopathology of the mechanical thrombectomy specimen, however,
revealed a papillary neoplasm composed of papillae with
hyalinized cores lined by endothelium (Fig 1), consistent with papillary fibroelastoma of cardiac origin.
The fact that transesophageal echocardiography did not
reveal any cardiac lesion is surprising but can be explained by complete embolization of the mass into the

cerebral circulation. On follow-up after 5 months, the
patient had recovered with only minimal aphasia and no
cardiac symptoms, with NIHSS score of 3 and mRS score
of 1. The patient will be monitored for development of
cardiac lesions in the future.
A similar case of total detachment of a papillary
fibroelastoma causing embolic stroke treated by mechanical thrombectomy in a 64-year-old patient has been
reported by Tejada et al.1 There are a few published series
of histopathology of mechanical thrombectomy specimens2-4
but they all report on different kinds of thrombus histology. Retrieval of piece of chordae tendineae in a patient
with embolus after mitral valve replacement surgery has
also been reported.5 Our experience with this case highlights the importance of histopathologic examination of
the thrombectomy specimen, as it provided the only clue
to the etiology of stroke.

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THROMBECTOMY SPECIMEN REVEALS CARDIAC TUMOR

References
1. Tejada J, Galiana A, Balboa O, et al. Mechanical
endovascular procedure for the treatment of acute ischemic
stroke caused by total detachment of a papillary
fibroelastoma. BMJ Case Rep 2013;2013:e37. doi:10.1136/
bcr-2013-010800.
2. Schuhmann MK, Gunreben I, Kleinschnitz C,
et al. Immunohistochemical analysis of cerebral
thrombi retrieved by mechanical thrombectomy from
patients with acute ischemic stroke. Int J Mol Sci
2016;17:298.

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3. Boeckh-Behrens T, Kleine JF, Zimmer C, et al. Thrombus
histology suggests cardioembolic cause in cryptogenic
stroke. Stroke 2016;47:1864-1871.
4. Ahn SH, Hong R, Choo IS, et al. Histologic features of
acute thrombi retrieved from stroke patients during
mechanical reperfusion therapy. Int J Stroke 2016;11:10361044.
5. Thomas MC, Delgado Almandoz JE, Todd AJ, et al. A case
of right middle cerebral artery “tendonectomy” following
mitral valve replacement surgery. J Neurointerv Surg
2017;9:e35. doi:10.1136/bcr-2016-012951. [Epub 2017 Feb
24].