A case of large atrial myxoma presenting as an acute stroke

Abstract

Left atrial myxomas are rare primary cardiac tumors. Their incidence is estimated to be about 0.1% of total cases. Neurological complications resulting from cardiac myxomas are seen in 20–35% of patients. Transesophageal echocardiogram (TEE) is preferred over transthoracic echocardiogram for evaluation of left atrial myxoma. Three-dimensional (3D) echocardiography ensures better visualization of intracardiac structures. It has been used prior to surgery for diagnostic support in the surgical treatment of cardiac masses. We present a case of a 46-year-old Hispanic male who developed acute ischemic stroke of left frontal lobe and was also found to have multiple ‘silent’ cerebral infarcts in the MRI of the brain. On further workup, he was found to have a left atrial myxoma on 3D TEE. This was resected with the assistance of intra-operative 3D TEE imaging. We present this case to increase awareness and to stress at early evaluation of secondary causes of ischemic cerebrovascular accident, outside the realm of hypercoagulability. This case also exhibits the need for basic cardiac workup in young individuals who present with symptoms of intermittent palpitations or chest pain to minimize significant morbidity or mortality.

Extracardiac manifestations of atrial myxomas

“…One states that it is derived from endocardial neural cells [15], while other literature states that myxomas originate from the embryonic foregut and are thus derived from multipotent mesenchymal cells capable of neural and epithelial differentiation. Although the etiology is not well understood, the majority of cases are sporadic and approximately 10% of myxomas are of the autosomal dominant genetic pattern (Carney’s complex) [16]. On gross anatomy, cardiac myxomas are often pedunculated and soft in consistency with a smooth, villous, or friable surface.…”

“…In specific to patients with myxomas, studies report that around 20–35% of them experience neurological complications [9] and 9–22% of these myxoma cases suffer from an embolic stroke [16]. Left atrial myxoma should always be included in the differential diagnosis in case of multiple cerebral infarcts, especially in young individuals [16]. A delayed neurological complication of a myxoma includes the development of cerebral aneurysms and myxomatous metastasis.…”

“…The diagnostic modality of choice is an echocardiography, which identifies the size, site, attachment, mobility, and also grossly differentiates the myxoma from vegetation or a thrombus [50]. Transesophageal echocardiography is preferred over transthoracic echocardiography [16]. Other diagnostic tests include a coronary angiography and magnetic resonance imaging.…”

Atrial Myxoma with a Dual Coronary Artery Supply

“…Myxomas are the most frequent benign form of heart tumour. The majority of the myxomas (85%), are located in the left atrium [3] [9]. Although the myxomas are histologically benign, they may nonetheless be lethal because of their position.…”

“…Symptoms are weak and nonspecif-ic, which makes early diagnosis a challenge. Symptoms could be presented as dyspnea, palpitations and atrial embolism [3] [4] [5].…”