Abstract
A 78-year-old woman presented to the emergency department with gait ataxia and diplopia.
Her past medical history included the surgical resection of a phyllodes breast tumour 8 years
prior, with no known recurrence. A computed tomography (CT) scan of the brain demonstrated
multifocal right supratentorial hemispheric subacute infarcts in the frontoparietal, posterior
temporal and occipital regions. The patient developed recurrent generalized seizures in hospital.
Transesophageal echocardiogram demonstrated a large 2.7 × 1.8 × 0.8 cm mobile echogenic
mass attached to the left posterior atrial wall. CT angiogram of the chest revealed the left atrial
mass as well as a mass encasing the right bronchus intermedius. The patient opted for comfort
care and passed away in hospital. Autopsy revealed the tumour to be a primary cardiac solitary
fibrous tumour. We present a case of multifocal ischemic stroke and seizures secondary to
tumour emboli originating from intracardiac solitary fibrous tumour.
RESUME
Une femme de 78 ans s’est présentée au service des urgences avec une ataxie et une diplopie de
la démarche. Ses antécédents médicaux comprenaient la résection chirurgicale d’une tumeur
à phyllodes au sein 8 ans auparavant, sans récidive connue. Une tomodensitométrie (TDM)
du cerveau a révélé des infarctus subaigus hémisphériques suprasensoriels droits dans les
régions frontopariétale, postérieure temporale et occipitale. Le patient a développé des crises
généralisées récurrentes à l’hôpital.
L’échocardiogramme transœsophagien a mis en évidence une masse échogène mobile importante
de 2,7 × 1,8 × 0,8 cm fixée à la paroi auriculaire postérieure gauche. La tomodensitométrie
thoracique révélait la masse auriculaire gauche ainsi qu’une masse recouvrant la bronche
intermédiaire. Le patient a opté pour des soins de confort et est décédé à l’hôpital. L’autopsie a
révélé que la tumeur était une tumeur fibreuse solitaire cardiaque primaire. Nous présentons
un cas d’accident vasculaire cérébral ischémique multifocal et de convulsions secondaires à une
embolie tumorale provenant d’une tumeur fibreuse solitaire intracardiaque.
Canadian Journal of General Internal Medicine
28 Volume 13, Issue 4, 2018
C a s e S t u d y
About the Authors:
Lindsay Melvin is an Assistant Professor in the Department of Medicine at the University of Toronto. Nicole Sitzer is a Respirologist
with a community practice. Rebecca Amer is an Associate Professor, Divisions of General Internal Medicine and Respirology,
Department of Medicine
Correspondence to Lindsay Melvin: lindsay.melvin@uhn.ca
Submitted: January 5, 2018. Accepted: April 8, 2018. Published: November 9, 2018. DOI: 10.22374/cjgim.v13i4.268
Tumour Emboli Causing Multifocal Ischemic
Stroke from Intracardiac Malignant Solitary
Fibrous Tumour
Lindsay Melvin MD, Nicole Sitzer MD, Rebecca Amer MD
Despite initial clinical suspicion of recurrence of her phyllodes
breast tumour with metastases, the final pathology was indicative
of a malignant solitary fibrous tumour.
Discussion
Approximately 20% of ischemic strokes are thought to be
cardioembolic in nature.
1
Features on clinical presentation suggestive
of cardioembolism include: decreased level of consciousness,
maximum severity of symptoms at onset with quick recovery of
deficits, symptoms involving multiple vascular territories of the
brain and the presence of non-central nervous system emboli.
Cardiac sources of cerebral emboli include valvular disease, left
atrial or ventricular thrombi, and cardiac tumours. Paradoxical
emboli may occur when there is reversal of flow through a patent
foramen ovale, atrial or ventricular septal defect.
1
Primary cardiac tumours are uncommon with rates reported
between 0.001–0.28%.
2–4
Over 75% of primary cardiac tumours
are benign. Secondary cardiac tumours are more common;
2.3–18.3% of patients with a primary neoplasm have cardiac
metastases on post-mortem examination. Secondary cardiac
tumours may arise from extension of a primary tumour or are
metastastic lesions from extracardiac malignancies.
3,5
Malignancies
which most commonly metastasize to the heart and pericardium
include mesothelioma, lung adenocarcinoma, melanoma, breast
carcinoma and lymphoproliferative neoplasms.
3,6,7
Clinical
manifestations of cardiac tumours vary depending on tumour
location. Patients may present with chest pain, heart failure,
pericardial effusion, or arrhythmia. Cardioembolic stroke as
a presenting feature of a cardiac tumour is an extremely rare
occurrence.
3,6
Solitary fibrous tumours (SFTs) are neoplasms of spindle
cells, which originate from mesenchymal cells. SFTs are usually
Case
A 78-year-old woman presented to the emergency department
with a 3-week history of ataxia and diplopia. Her past medical
history was significant for surgical resection of a phyllodes
breast tumour with no known recurrence of disease. Physical
examination revealed a left cranial nerve III palsy, ataxia and
left-sided weakness. A non-contrast computed tomography
(CT) head demonstrated multifocal subacute infarcts in the
frontoparietal, posterior temporal and occipital regions. A
transthoracic echocardiogram showed no evidence of an
intracardiac mass.
The patient developed recurrent generalized seizures
during her hospitalization. Magnetic resonance imaging of the
head confirmed multifocal acute ischemic infarcts suggestive
of a cardio-embolic source. CT of the chest demonstrated a 3.3
cm bi-lobed atrial mass on the posterior wall of the left atrium,
extending into the right inferior pulmonary vein and encasing
the right bronchus intermedius (Figure 1). Several nodules in
the peripheral branches of the pulmonary vein were also present.
A transesophageal echocardiogram confirmed the presence of a
large 2.7 × 1.8 × 0.8 cm mobile echogenic mass attached to the
posterior left atrial wall which was not seen on the transthoracic
imaging (Figure 2).
The patient opted for non-acute management of her disease
and died twomonths later. A limited autopsy revealed a 5 × 4
× 3 cm malignant solitary fibrous tumour in the left atrium
invading the left ventricle, interventricular septum and epicardial
fat (Figure 3). The tumour also extended into the pulmonary
vein and infiltrated the vessel wall. Multiple branches of the
pulmonary vein were filled with emboli-like tumour nodules.
The tumour demonstrated areas of hypercellularity, necrosis, and
high mitotic activity, consistent with a high-grade malignancy.
Figure 1. Computed tomography of the chest demonstrating a bi-lobed atrial mass on the posterior wall of the left atrium measuring 3.3 cm and extending
into the right inferior pulmonary vein.
Canadian Journal of General Internal Medicine
Volume 13, Issue 4, 2018 29
Chan et al.