Cardiac intimal sarcoma presenting as basilar artery occlusion treated with tenecteplase and thrombectomy: a case report.

Background: Cardiac intimal sarcoma is a rare and aggressive malignancy, often presenting with embolic complications such as stroke. Basilar artery occlusion (BAO) is a life-threatening neurological emergency caused by several mechanisms, most commonly embolism (including cardioembolism) and intracranial atherosclerotic disease (with thrombotic occlusion). Case presentation: A 77-year-old man with a history of coronary heart disease, cerebral infarction, and hypertension presented with acute speech impairment and progressive consciousness disturbance. NIHSS score was 28. The electrocardiogram showed atrial fibrillation. Non-contrast head computed tomography ruled out hemorrhage. Intravenous tenecteplase (22.5 mg) was administered before platelet count results were available, which later revealed thrombocytopenia (54 × 10⁹/L). Emergency mechanical thrombectomy retrieved a 4-cm thrombus from the basilar apex. Histopathology and immunohistochemistry confirmed a diagnosis of intimal sarcoma. Post-procedure, the patient developed multi-organ bleeding and coagulopathy, requiring continuous renal replacement therapy. Despite successful revascularization (NIHSS improved to 10), the patient succumbed to complications of advanced malignancy and hematologic dysfunction. Conclusions: This case highlights that cardiac intimal sarcoma can present as acute BAO. Histopathological analysis of thrombectomy-retrieved embolic material can establish the diagnosis, obviating the need for invasive cardiac biopsy. Intravenous thrombolysis in the setting of unrecognized thrombocytopenia or malignancy-associated hemostatic dysfunction may carry substantial bleeding risk and warrants careful patient selection, urgent laboratory confirmation when feasible, and multidisciplinary management.