15-year-old girl with acute cerebral infarction, intravenous thrombolysis has not improved!

*For medical professionals' reference only, do you think intravenous thrombolysis should be performed for this type of cerebral infarction? Clinically, patients with cerebral infarction who meet the indications for thrombolysis and have no corresponding contraindications will be treated with intravenous thrombolysis, which usually has a significant effect.

However, this patient is quite different.
After intravenous thrombolysis, the effect is not good and the symptoms are getting worse.
Why? Not much to say, let's just look at the case [1]! Case review: A 15-year-old female patient was admitted to the hospital mainly because of "sudden disturbance of consciousness with weakness of right limb for 3 hours".

At 9:00 am on the day of admission, the patient suddenly became unconscious during the physical examination (skipping rope), did not respond to the call, the left limb was involuntary, the right limb was painful and immovable, accompanied by lip shaking, no vomiting, no vomiting, and eyes Turning, tongue bite, limb shaking, urinary incontinence and other symptoms were sent by the teacher to the local county people’s hospital.
There was no hemorrhage on the head CT.
The initial consideration was “cerebral infarction”; the patient’s parents agreed at 10:00 am Later, he was given 49.
5 mg intravenous thrombolytic therapy with "recombinant tissue-type plasminogen activator".
The intravenous thrombolysis ended at 11:00.
The patient's consciousness did not improve, and his limbs did not improve significantly.
He went to the emergency department of our hospital for further diagnosis and treatment.

After being admitted to our hospital emergency department, she suffered from urinary incontinence twice, and she was given intravenous infusion of "dexmedetomidine".
After sedation, she underwent thrombus removal from the left middle cerebral artery at 15:40, and was admitted to our intensive care unit after the operation.

Since the onset of the onset, the patient has been confused, has not eaten, has urinary incontinence, has no stool, and has no significant changes in weight.

Past history: past physical fitness, denying history of high blood pressure, heart disease, and diabetes.

[Physical examination] Body temperature 37.
0℃, pulse 55 beats/min, breathing 20 beats/min, blood pressure 102/60 mmHg, confusion (intravenous dexmedetomidine), uncooperative physical examination.

The neck is soft and without resistance.

The pupils on both sides are equi-circular, with a diameter of 3.
0 mm, sensitive to light reflection, and both eyes are staring to the left.The nasolabial fold on the right side is shallow, and the tongue extension examination cannot cooperate.

Spontaneous movement of the left limb can be seen, the painful stimulation of the right limb can only move slightly on the bed surface, the muscle tone of the right limb is reduced, the bilateral tendon reflexes (++), the right Babinski sign is positive, and the left Babinski sign Sign negative.

[Auxiliary examination] Before surgery: 1.
Brain CT showed cerebral infarction in the left temporal, parietal, occipital, insula and basal ganglia (Figure 1A); 2.
DSA of the left common carotid artery showed the initiation of the left middle cerebral artery Occlusion (Figure 2A, B); 3.
Color Doppler ultrasound at the bedside of the hospital admission may suggest atrial myxoma (Figure 3A); 4.
Color Doppler ultrasound showed that the left atrium was about 3.
8 cm×2.
7 cm with a strong echogenic mass, indicating left atrial mucus Tumor (4A).

After mechanical thrombectomy: 1.
Postoperative cranial CT showed high-density shadows in the left basal ganglia area (Figure 1B), considering the possibility of contrast agent extravasation; re-examine the cranial CT 24 hours after surgery (Figure 1C), See the disappearance of the high-density shadow, which was confirmed to be caused by the extravasation of the contrast agent; 2.
The re-examination showed that the left middle cerebral artery was recanalized and the blood perfusion was completely restored (Figure 2C, D); 3.
The extracted material was a yellow transparent jelly (Figure 3B), embolic material biopsy revealed a myxoma tendency.

[Treatment] The medical history was followed up after the operation.
The family members complained that the patient had headache, nausea, and weakness of the limbs after morning exercises (jogging 900 m) every day for the past 2 months, and returned to normal after more than 10 minutes.
There was no chest swelling or palpitations.
Pay attention.

According to the patient’s recent 2 months’ medical history, intraoperative findings and bedside cardiac color Doppler ultrasound results, atrial myxoma is likely to cause embolic cerebral infarction.
In order to reduce the patient’s emotional irritability and cause the myxoma to fall off, continue dexmedetomidine after surgery Sedative treatment.

Considering that the embolized tissue is not thrombosis, anti-platelet aggregation treatment was not performed, and only dehydration to lower intracranial pressure, limb rehabilitation, acupuncture and symptomatic supportive treatment were given.

[Follow-up] The patient's condition was stable, and the brain CT was re-examined (Figure 1I), the bleeding was completely absorbed, and the family members asked to be discharged from the hospital.

Atrial myxoma was excised in the Department of Cardiac Surgery 1 week after discharge.
Specimen and pathological biopsy revealed myxoma (Figure 4C, D).
The diagnosis of embolic cerebral infarction caused by atrial myxoma was clear.
Follow-up 3 months later, the patient can hold something in his right hand.
The modified Rankin scale scores 1 point.

Figure 1 Brain CT of the patient during hospitalization.

A: CT of the patient's skull before thrombus removal (June 25, 2019): White arrow shows the disappearance of the sulcus/low density; B: After thrombus removal, the CT of the skull (June 25, 2019) shows high-density shadows (white arrow) C: Reexamination of the brain CT after thrombolysis for 24 hours (June 26, 2019) showed that the high-density shadow disappeared, which was the extravasation of contrast agent, but the midline was shifted and the lateral ventricle was compressed; D, E: Reexamination of the brain CT (June 27 and 28, 2019) Show: The midline shift is not obvious, but it can be seen that there is residual normal brain tissue in the infarct.
Part of the ischemic penumbra has been rescued; F: Brain CT shows (July 2019 2nd) The swelling of the patient’s brain tissue was reduced, and the midline was closer to the longitudinal fissure; G: The white arrow shows the high-density shadow of the temporal parietal lobe, which is post-infarction combined with hemorrhagic transformation (July 9, 2019); H: July 21, 2019 Brain CT showed that there were still scattered high-density shadows in the temporal parietal lobe and basal ganglia area, but it was significantly absorbed compared to the CT on July 9 (arrow); I: CT on August 4, 2019 showed: temporal and parietal insula The high-density contrast (bleeding) has been completely absorbed Figure 2 Digital Subtraction Angiography (DSA) before and after the patient's thrombus is removed.

A, B: The left middle cerebral artery was completely occluded under DSA before thrombectomy, without visualization; C, D: The left middle cerebral artery was recanalized under DSA after thrombectomy, and the visualization was clear.
Figure 3 The patient’s bedside cardiac color Doppler ultrasound , Middle cerebral artery embolism and its pathological biopsy (biopsy).

A: Bedside cardiac color Doppler ultrasound showed a solid isoechoic mass (arrow) with a size of approximately 3.
5 cm×2.
8 cm in the left atrium, with a pedicle attached to the atrial septum, suggesting a possible atrial myxoma; B: mechanical removal of the left middle cerebral artery during surgery The translucent yellow jelly-like embolism obtained from the embolism; C~E: The pathological biopsy results of the cerebral artery embolism showed that the tumor cells were distributed in the basophilic mucus matrix, the tumor cells were spindle-shaped and star-shaped, and the cytoplasm was fused with each other.
The distribution of blood vessels (C: ×200, D, E: ×100, HE staining) can be seen in the cytoplasm, suggesting a preference for myxoma.
Figure 4 Cardiac color Doppler ultrasound (A, B) and postoperative specimens before and after myxoma resection ( C) and pathological results (D). A: The patient’s preoperative cardiac color Doppler ultrasound indicated atrial myxoma (arrow); B: The patient’s reexamination of the cardiac color Doppler ultrasound after the operation, the arrow indicates that the atrial myxoma was completely resected, and each heart cavity was normal in size; C: The patient’s myxoma resected during the operation; D: Pathological biopsy of myxoma revealed scattered interstitial lymphoplasmic cell infiltration, and the diagnosis was left atrial myxoma with HE stain ×200.
Figure 5 Treatment flow chart discussion 1 Why did this patient not improve significantly after intravenous thrombolysis? This patient is a young woman who has an acute onset under active conditions, and her condition quickly reaches a peak.
Symptoms and signs tend to block large blood vessels, which is in line with the characteristics of embolism.
However, the family denied that the patient had previous common causes of embolism such as heart disease.

After intravenous thrombolysis was given to the patient and no effect was seen, the artery was immediately bridged and mechanically removed.
The yellow transparent jelly object biopsy and the postoperative cardiac color Doppler ultrasound showed that the embolus tended to be myxoma; cardiac surgery removed the atrial mass and re-pathologically The biopsy revealed atrial myxoma, which was diagnosed as cardiogenic embolism, which also showed from the side that the reason for the poor efficacy of intravenous thrombolysis is related to myxoma.

2Why did you not use antiplatelet drugs during the treatment? The patient’s low responsiveness to recombinant tissue-type plasminogen activator was mainly due to the lysed tumor becoming part of the embolus.

Therefore, it is considered that the embolized tissue is not thrombosis, so no anti-platelet aggregation treatment is given.
Only dehydration to lower intracranial pressure, limb rehabilitation, acupuncture and symptomatic supportive treatment are given.

3Does the cerebral infarction caused by atrial myxoma need thrombolysis? The effect of intravenous thrombolysis for acute cerebral infarction caused by atrial myxoma depends on the components of the embolus, but combined with previous literature reports [2-4], early intravenous thrombolysis has been achieved in some patients with cerebral infarction caused by atrial myxoma.
The curative effect, the reason may be related to the incomplete organizing of the fresh thrombus.

For acute large vessel occlusion caused by atrial myxoma tumor itself, intravenous thrombolysis is almost impossible to achieve vascular recanalization; a foreign meta-analysis showed that the vascular recanalization rate after mechanical thrombus removal for middle cerebral artery occlusion is as high as 81% [5]; According to my country's guidelines for endovascular treatment of acute large vessel occlusion and ischemic stroke in 2019 [6], the benefit of endovascular treatment for patients with acute occlusion of the proximal middle cerebral artery is clear.

Therefore, for patients with myxoma whose intravenous thrombolysis is ineffective, in order to save the ischemic penumbra, endovascular treatment can be used after contraindications are eliminated.

When intravenous thrombolysis is ineffective, bridging mechanical thrombectomy may be a better choice for the treatment of these occluded segments, especially when the large blood vessels in the brain are involved.

Tadi et al.
[7] described a 32-year-old patient with atrial myxoma caused by a stroke that recurred cerebral infarction one week after the onset of onset.
Therefore, in order to avoid re-embolization and cause adverse consequences, once the diagnosis of myxoma is clear, there is no contraindication.
The next should be surgically removed immediately. References: [1] Wei Heng, Yao Xiaodong, Sun Yaxuan, etc.
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