Ultrasonography in embolic stroke: the complementary role of transthoracic and transesophageal echocardiography in a case of systemic embolism by tumor invasion of the pulmonary veins in a patient with unknown malignancy involving the lung

Abstract

Two-dimensional transthoracic echocardiography is commonly performed to detect a possible cardiac source of systemic embolism and it has been the mainstay of detection and diagnosis of cardiac masses. The transesophageal approach has enhanced the ability to detect cardiac sources of embolism by allowing a better visualization of posterior cardiac structures such as the left atrium with left atrial appendage, pulmonary veins and thoracic aorta and by providing higher resolution images to improve assessment of the presence and extent of cardiac masses. In this case report, echocardiography, using both transthoracic and transesophageal approach, allowed to detect a neoplastic mass arising from the upper left pulmonary vein in a patient presented with a transient ischemic attack. Further investigations showed a malignancy involving the lung. To our knowledge, this is the first reported case in which a cerebral embolic episode represents the clinical onset of a lung cancer, pointing out the importance of echocardiography in all cases of undetermined cerebral ischemic attack.

Left Atrial Mass Invasion from Pulmonary Neoplasm Extension via the Right Upper Pulmonary Vein Presenting as Ipsilateral Stroke

“…Patients most commonly suffer symptoms related to lung cancer (e.g., cough, hemoptysis, and weight loss) or sometimes related to cardiac complications as the first clinical presentation. A limited number of reports previously described cardiovascular presentations secondary to systemic neoplastic embolization, including cerebral ischemia [29–31] or peripheral arterial occlusion [32]. Noteworthy, most previous reports of cerebral ischemia described events with typical contralateral presentation [12, 29] or incidental detection of brain ischemic lesion by imaging techniques in asymptomatic subjects [30, 31].…”

Left atrial thrombus following bilobectomy: a case report

“…The pathophysiology may be growth of the thrombus in the left atrium and taking on the shape of the cavity, and then becoming a pedunculated mobile mass [2]. The free thrombus in the left atrium can be highly thromboembolic [4]. …”

Lung Cancer With Tumor Emboli

“…Persistently large chylous drainage by about the fifth postoperative day often necessitates surgical reexploration and thoracic duct band ligation. Surgical management is, however, associated with significant morbidity (40%) and mortality (25%), in addition to not always leading to successful cessation of chylous leakage [3,4]. We report a case of successful medical management of persistently large chylous drainage (despite surgical reoperation and band ligation) using high-dose intravenous octreotide.…”

“…Chylous leakage is initially treated with pleural drainage, bowel rest, total parenteral nutrition, and fluid replacement [4]. Enteral diets rich in medium chain triglycerides are sometimes used as an alternative to total parenteral nutrition.…”

“…Many primary tumor emboli described in the literature have been adenocarcinoma, and the majority of emboli from metastatic lung tumors are sarcomas [1][2][3]. Tumor embolus most commonly occurs at the aortic bifurcation or the femoral vessels (50%) and in the cerebral circulation (30%) [4]. Other, less common locations of emboli include the contralateral lobe of the lung from an endobronchial primary tumor [5], lower and upper extremities, the renal arteries, and the splenic artery [6].…”