Transient ischaemic attack: a common initial manifestation of cardiac myxomas

Case Report: Left atrial myxoma with confirmed Delta variant COVID-19 infection, "to treat or withhold"

Primary cardiac tumors (PCTs) are extremely rare entities. More than half of PCTs are benign, with myxoma being the most common tumor. Generally, simple tumor resection is the treatment of choice for benign PCTs since it has promising results that yield low complication and recurrence rates. However, in the COVID-19 pandemic era, the mitigation protocols and/or concurrent COVID-19 infection should be taken into account in patient management for the best overall outcome. To our knowledge, this is the first case report of a patient with a left atrial myxoma and systemic embolism complication in the form of an ischemic stroke, with a concurrent confirmed COVID-19 delta variant infection.

Cerebral embolization associated with parenchymal seeding of the left atrial myxoma: Potential role of interleukin-6 and matrix metalloproteinases

Systemic embolization has been reported in up to 40% of patients with left atrial myxoma, half of them with cerebral involvement. However, development of intracerebral embolization associated with parenchymal seeding of the myxoma emboli is an extremely rare complication, with only 36 histologically diagnosed cases reported in the published literature. We describe a 69-year-old woman who arrived at the emergency service with hemiparesis associated with drug-resistant epilepsy and a medical history of resection of a left atrial myxoma 10 months previously. Cranial computed tomography revealed multiple large lesions of heterogeneous density and cystic components in the occipital lobes and posterior fossa parenchyma. Histopathological analyses after stereotactic biopsy of the occipital lesion revealed infiltrative myxoma cells with benign histological findings and uniform expression of calretinin similar to that of the primary cardiac myxoma. Additional immunohistochemical studies confirmed brain parenchymal seeding of the myxoma cells with strong expression of interleukin-6 (IL-6) and focal expression of matrix metalloproteinases-2 (MMP-2). Here, we discuss the clinicopathological features of intracerebral embolization of left atrial myxomas associated with progressive parenchymal seeding of the tumor emboli and the potential pathogenic role of IL-6 and MMPs.

Neurological manifestations of atrial myxoma: A retrospective analysis

Atrial myxoma is the most common type of primary cardiac tumor and it is closely associated with stroke in adults. Early diagnosis and treatment of atrial myxomas is essential for the prevention of embolic events. The aim of the present study was to assess neurological complications associated with atrial myxoma. The neurological signs of atrial myxoma were retrospectively assessed in individuals who underwent treatment at West China Hospital (Chengdu, China) and The Affiliated Hospital of Hainan Medical University (Haikou, China), between March 2003 and February 2015. A total of 130 patients with atrial myxoma were included and 22 (17%) exhibited neurologic signs. These patients were aged 39.9±12.6 years (range, 13-78 years) and there were 13 female and 9 male patients. Ischemic cerebral infarct constituted the dominant clinical symptom (68.2%) and 3 patients exhibited concomitant cardiac manifestations. Atrial myxoma was diagnosed by echocardiography in all patients. Irregular surface of atrial myxomas was associated with a high risk of embolic events. The patients with myxoma successfully underwent surgery with no mortality recorded. In conclusion, atrial myxomas frequently manifest as cerebral infarction in individuals without cardiovascular risk factors. These tumors more commonly affect the middle cerebral artery. Irregular surface of myxomas appears to be associated with embolic events. Echocardiography may improve the diagnosis and early treatment of atrial myxomas.

Heart or head?: A depression mimic delays diagnosis-oncotic cerebral aneurysms caused by atrial myxoma

Complications of intracardiac tumours can carry significant morbidity and mortality. This article depicts the case of a female who presented with multiple oncotic intracranial aneurysms secondary to a left atrial myxoma. The clinical manifestations and pathogenesis of cardiac myxoma, as well as the imaging pathway, management and prognosis of myxomatous aneurysms will be discussed. Excision of the cardiac mass is mandatory both for symptomatic improvement and to prevent further embolic complications. Local recurrence and delayed onset cerebral complications do occur, and necessitate ongoing patient follow-up. Our report highlights several important features of the diagnostic and treatment pathway for atrial myxoma-in particular, the potentially non-specific clinical presentation, the pivotal role of cardiac MRI in the multimodality diagnostic imaging work up and the need for multidisciplinary communication to identify the diagnosis and guide appropriate management.

Stroke of a cardiac myxoma origin

Objective

The clinical features of cardiac myxoma stroke have not been sufficiently described. Debates remain concerning the options and timing of treatment and the clinical outcomes are unknown. This article aims to highlight the pertinent aspects of this rare condition.

Methods

Data source of the present study came from a comprehensive literature collection of cardiac myxoma stroke in PubMed, Google search engine and Highwire Press for the year range 2000-2014.

Results

Young adults, female predominance, single cerebral vessel (mostly the middle cerebral artery), multiple territory involvements and solitary left atrial myxoma constituted the outstanding characteristics of this patient setting. The most common affected cerebral vessel (the middle cerebral artery) and areas (the basal ganglion, cerebellum and parietal and temporal regions) corresponded well to the common manifestations of this patient setting, such as conscious alteration, ataxia, hemiparesis and hemiplegia, aphasia and dysarthria. Initial computed tomography scan carried a higher false negative rate for the diagnosis of cerebral infarction than magnetic resonance imaging did. A delayed surgical resection of cardiac myxoma was associated with an increased risk of potential consequences in particular otherwise arterial embolism. The mortality rate of this patient population was 15.3%.

Conclusion

Cardiac myxoma stroke is rare. Often does it affect young females. For an improved diagnostic accuracy, magnetic resonance imaging of the brain and echocardiography are imperative for young stroke patients in identifying the cerebral infarct and determining the stroke of a cardiac origin. Immediate thrombolytic therapy may completely resolve the cerebral stroke and improve the neurologic function of the patients. An early surgical resection of cardiac myxoma is recommended in patients with not large territory cerebral infarct.

Risk prediction for emboli and recurrence of primary cardiac myxomas after resection

BACKGROUND

Risk factors for embolism and recurrence of primary cardiac myxoma are not well established. This study aimed to assess the risk factors for embolism and recurrence of cardiac myxoma, as well as the survival of the patients.

METHODS

The medical records of 207 consecutive patients treated for primary cardiac myxoma between September 1988 and October 2014 were retrospectively analyzed. All diagnoses were pathologically confirmed. Data were collected to identify the risk factors influencing the prognosis.

RESULTS

Mean age at surgery was 44.2 ± 15.8 years. Operative mortality (within 30 days of the surgery) occurred in seven patients. Mean follow-up was 9.35 ± 6.55 years. Embolism occurred in 32 (15.5 %) patients before surgery. Multivariate analysis indicated that small (≤ 4.5 cm) myxoma (OR = 5.14; 95 % CI, 2.30-11.94; P < 0.0001) and soft, gelatinous myxoma (OR = 5.84; 95 % CI, 1.91-25.61; P = 0.001) were independently associated with the occurrence of embolism. Ten patients experienced recurrences. After excluding the patients who died within 30 days of surgery, survival was 92.7 % at 10 years. Age, sex, tumor size, cardiopulmonary bypass duration, aortic cross clamp duration, tumor appearance, and pre-operative embolism were not associated with early mortality. Multivariate analysis showed that multicentric myxomas were independently associated with recurrence (OR = 9.45, 95 % CI, 2.15-41.3, P = 0.004).

CONCLUSIONS

The surgical resection of primary cardiac myxoma is associated with excellent long-term survival. Tumors ≤ 4.5 cm and soft tumors were independent risk factors for embolism. Multicentric cardiac myxoma was an independent risk factors for recurrence of myxoma.

Left atrial myxoma with versus without cerebral embolism: length of symptoms, morphologic characteristics, and outcomes

The aim of this study was to evaluate the embolic sequelae of left atrial myxomas and their influence on diagnosis, treatment, and prognosis. Seventy-eight patients were retrospectively investigated. According to their symptoms and neurologic-imaging findings, these patients were classified into 2 groups: embolism (15 patients, 19%) and nonembolism (63 patients, 81%). The time from the first onset of symptoms to diagnosis (that is, the duration of symptoms) was significantly longer in the embolism group than in the nonembolism group (105 ± 190 vs 23 ± 18 d; P <0.01). The myxomas were divided into 2 types on the basis of clinicopathologic findings: type 1, with an irregular or villous surface and a soft consistency, and type 2, with a smooth surface and a compact consistency. There were 42 patients with type 1 myxoma and 36 with type 2. Type 1 myxoma was more frequently found in the embolism group (12 patients, 29%) than was type 2 myxoma (3 patients, 8%). The difference was significant (P=0.04). There were 2 perioperative deaths in the nonembolism group. No recurrence of cardiac myxoma or death was recorded in either group during follow-up. In the embolism group, neurologic symptoms were relieved by surgery, and no subsequent neurologic event was reported. Because surgical resection is highly effective in left atrial myxoma, we should strive for early diagnosis in order to shorten the duration of symptoms and to avoid worse neurologic damage in patients in whom an embolic event is the initial manifestation.

Neurologic complications of cardiac tumors

Cardiac tumors are an uncommon cause for neurologic disease, but if undiagnosed can be associated with devastating neurologic consequences. Primary cardiac tumors, both benign and neoplastic, and metastatic tumors occur. Primary cardiac tumors are more likely to be associated with neurologic embolic complications. Metastatic cardiac tumors are more likely to be associated with valvular distraction, arrhythmia, diminished cardiac output and indirect neurological dysfunction. Primary and metastatic cardiac tumors may result in cerebral metastatic disease. Atrial myxoma, a benign primary cardiac tumor, is the most common cardiac tumor associated with neurologic disease, and most commonly causes cerebral embolization and stroke. The use of thrombolytic therapy for these strokes is controversial. Additionally, delayed manifestations, including aneurysm formation and intracranial hemorrhage, are possible. Aneurysm formation has been described as occurring after removal of the primary tumor. The availability of noninvasive cardiac imaging has significantly helped decrease the neurologic morbidity of cardiac tumors and has led to frequent successful intervention.

A large left atrial myxoma causing multiple cerebral infarcts

A 52-year-old man presented with a history of sudden onset diplopia. On neurological examination, the only abnormality was a right-sided oculomotor (third nerve) palsy. A brain CT was performed and reported as showing no abnormality. He was discharged to be investigated as an outpatient. He presented 1 month later with a new expressive dysphasia and confusional state. MRI was performed which revealed multiple cerebral infarcts. He was discharged on secondary stroke prevention medication. Six months elapsed, before a transthoracic echocardiogram was performed. This showed a large left atrial myxoma. The patient underwent an emergency resection and made a good postoperative recovery. This case report showed the importance of considering a cardiogenic source of emboli in patients who present with cerebral infarcts. Performing echocardiography early will help to detect treatable conditions such as atrial myxoma, and prevent further complications.

Neurological manifestations of cardiac myxoma: experience in a referral hospital

INTRODUCTION

Cardiac myxoma is an important but uncommon cause of stroke in younger patients. Few published case series analyse the frequency and clinical presentation of neurological complications in patients with myxoma.

OBJECTIVE

To list all neurological complications from cardiac myxoma recorded in our hospital in the past 28 years.

PATIENTS AND METHODS

We retrospectively reviewed the neurological manifestations of cardiac myxoma in patients treated in our hospital between December 1983 and March 2012.

RESULTS

Of the 36 patients with cardiac myxoma, 8 (22%) presented neurological manifestations. Half were women and mean age of patients was 52.4 ± 11.6 years. Sudden-onset hemiparesis was the most frequent neurological symptom (63%). Established ischaemic stroke was the most common clinical manifestation (75%), followed by transient ischemic attack. The most commonly affected territory corresponded to the middle cerebral artery. Myxoma was diagnosed by echocardiography in all cases. Mean myxoma size was 4.1cm and most of the tumours (63%) had a polypoid surface. All tumours were successfully removed by surgery. There were no in-hospital deaths.

CONCLUSIONS

Cardiac myxomas frequently present with neurological symptoms, especially ischaemic events (established stroke or transient ischaemic attack), in younger patients with no cardiovascular risk factors. The anterior circulation is more frequently affected, especially the middle cerebral artery. Echocardiography can facilitate prompt diagnosis and early treatment of the lesion.

Intravenous Thrombolysis for Embolic Stroke due to Cardiac Myxoma

Cardiac myxoma is a rare but curable cause of ischemic stroke. Current guidelines do not address the use of intravenous thrombolysis for embolic stroke caused by cardiac myxoma. The risk of hemorrhage due to occult tumor emboli or microaneurysms is a major concern. We describe a 45-year-old man who had an embolic stroke in the left middle cerebral artery. The initial National Institutes of Health Stroke Scale (NIHSS) score was 16. He received intravenous thrombolysis 2 h and 52 min after stroke onset. No intracranial hemorrhage developed. A cardiac mass was found in the left atrium and removed surgically 84 h after stroke. Pathological study showed a myxoma with extensive hemorrhage and thrombus over the surface. At the 3-month follow-up, the NIHSS score was 9 and the modified Rankin scale score was 3. Our experience with this patient supports the hypothesis that intravenous thrombolysis may be safely used in the treatment of embolic stroke due to cardiac myxoma.

[Ischemic strokes related to benign primitive cardiac tumours]

BACKGROUND

We report three cases of ischemic cardioembolic strokes related to benign primary cardiac tumours (two fibromas and one fibroelastoma).

CASE REPORTS

This is a retrospective study over a five years period (from December 2004 to December 2009) in a French community hospital. Data on hospital strokes were obtained from the informatics department. Three benign primary cardiac tumours were found as the cause of acute neurological manifestations: a 45-year-old woman with a fibroelastoma revealed by a brain infarction, a 29-year-old man with a myxoma revealed by a transient ischemic attack, and a 46-year-old woman with a myxoma revealed by a brain infarction. Rankin scores performed at least 18 months after cardiac tumour surgery were respectively of 0, 0 and 2.

CONCLUSION

Our study confirms that this is a rare event even if those tumours seem to have a high embolic potential (myxomas). Anyway, long-term functional outcome seems to be good.

Embolic atrial myxoma causing aortic and carotid occlusion

BACKGROUND

Cardiac myxomas are a rare but well-described cause of stroke that usually occur in young people. Cardiac myxoma can embolize to multiple sites throughout the body.

CASE DESCRIPTION

A 45-year-old woman presented acutely with altered mental status and signs of lower extremity vascular occlusion. Pathologic studies confirmed the diagnosis of cardiac myxoma.

CONCLUSIONS

This is the first case reported in the English literature of simultaneous aortic and internal carotid artery occlusion from embolism of an atrial myxoma without evidence of intracardiac tumor on transesophageal echocardiogram.

Clinical presentation and investigation findings in cardiac myxomas: new insights from the developing world

BACKGROUND

Cardiac myxomas are an uncommon condition and most of the available information on their clinical features comes from smaller series of patients from developed countries. Our aim was to quantify and correlate the clinical and investigation findings in cardiac myxomas in a developing country and compare them with existing data.

METHODS

A retrospective study of case notes, electrocardiograms, and x-rays of 171 patients treated for cardiac myxoma from February 1992 to October 2006 at a large charitable institution in South India was conducted. Frequency of different clinical findings and relationships between these findings, age, sex, tumor location, and size were calculated.

RESULTS

The mean age at presentation was 37.1 years. Dyspnea was the most common symptom. Embolism was found in 9% of patients and systemic symptoms in 20% of patients. Auscultation abnormalities were present in 89% of patients, including a tumor plop in 50%. Left atrial enlargement was the most common electrocardiographic abnormality (35%), whereas cardiomegaly was the most common chest x-ray finding (55%). Raised erythrocyte sedimentation rate was found in 75% and anemia in 45% of patients. Female patients and patients with right atrial myxomas more commonly had systemic symptoms. Tumor size correlated with electrocardiographic and x-ray abnormalities.

CONCLUSIONS

Cardiac myxomas present at a younger age in developing countries. Almost all patients were symptomatic because they presented for medical care at an advanced stage of disease. Certain clinical manifestations depend on site and size of the tumor as well as age of the patient. A high index of suspicion is necessary for making an early diagnosis.

Atrial myxomas: pathologic types, tumor location, and presenting symptoms

BACKGROUND

Atrial myxoma is the most common cardiac neoplasm. Although not widely reported, two anatomic types have been observed: solid and papillary. We examined whether differences in gross or microscopic appearance and location correlated with symptomatology, specifically congestive heart failure (CHF), neurologic symptoms, and embolic events.

METHODS

We performed a retrospective review of atrial myxomas removed from 1972 to 2002, recording the clinical presentation, diagnostic modality, tumor location, gross, and microscopic features for each patient. Twenty-six patients (16 females and 10 males) had atrial myxomas excised. Two patients (one female and one male) were excluded due to unavailable pathologic slides.

RESULTS

In 24 patients there were 15 solid and 9 papillary tumors. CHF was more prevalent in solid myxomas, while neurologic symptoms and embolic events were more common in papillary tumors. Tumor location further correlated with presenting symptoms. Ninety-two percent of patients presenting with CHF had tumors attached to the atrial septum. Extraseptal myxomas more frequently presented with neurologic (80% vs. 29%) and embolic features (50% vs. 25%). All patients exhibiting clefted tumor surface had a history of embolization. A higher percentage of solid myxomas (93%) showed hemorrhage within the tumor than with papillary (56%).

CONCLUSIONS

CHF was more common with solid myxomas, and neurologic and embolization events were more common in the papillary type. Septal tumor location showed strong association with CHF, while extraseptal location correlated with neurologic events. We speculate that the various gross and microscopic patterns reflect secondary changes within these neoplasms over the course of their natural history.

Anticipated diagnosis of left atrial myxoma following histological investigation of limb embolectomy specimens: a report of two cases

Nonfamilial myxoma occurs as a random event. The tumor is rare and can mimic other diseases. Cardiac myxomas should always be considered as a source of embolization, which need meticulous investigation and prompt indication of surgical resection. Tumors with a villous surface are prone to embolize. We report two cases of cardiac myxoma presenting as acute ischemia of one or two limbs due to embolic phenomena. The patients were females aged 55 and 37 years. Histological study of emboli taken from obstructed limb arteries in the two patients showed a picture indicating systemic embolization of a cardiac myxoma. The embolic tissue fragments showed the gross characteristics (i.e. villous surface) of the cardiac tumor. Further echocardiography and surgical removal confirmed the cardiac myxoma. Immunohistochemical study of embolectomy material disclosed strong reactivity of the tumor cells for calretinin. The histological examination of the embolectomy material can anticipate the cardiac lesion and its gross features. Calretinin is a useful marker in the differential diagnosis of cardiac myxoma with a myxoid thrombus. The necessity of histological examination of the embolectomy material is stressed.