Cardiac Myxoma Embolization Causing Ischemic Stroke and Multiple Partially Thrombosed Cerebral Aneurysms

HomeStrokeVol. 52, No. 1Cardiac Myxoma Embolization Causing Ischemic Stroke and Multiple Partially Thrombosed Cerebral Aneurysms Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree ArticlePDF/EPUBCardiac Praveen Kesav, DM Seby John, MD Priti Joshi, Waqar Haider Gaba, Syed Irteza HussainMD KesavPraveen Kesav Department of Neurology, Neurological Institute (P.K.), Cleveland Clinic Abu Dhabi, UAE. Search for more papers by this author , JohnSeby John Neurology Neurointerventional Surgery, (S.J., S.I.H.), JoshiPriti Joshi https://orcid.org/0000-0003-1638-2480 UAE (P.J.). GabaWaqar Gaba https://orcid.org/0000-0002-5581-3901 Sheikh Khalifa Medical City, (W.H.G.). HussainSyed Hussain Correspondence to: Hussain, MD, Institute, PO Box 112412, Al Maryah Island, Email E-mail Address: [email protected] https://orcid.org/0000-0002-5086-8030 Originally published20 Nov 2020https://doi.org/10.1161/STROKEAHA.120.031679Stroke. 2021;52:e10–e14A 31-year-old male South Asian origin, with no known vascular risk factors, presented evaluation acute onset impaired comprehension slurring speech. He also reported holocranial headaches 2 weeks duration telltale features raised intracranial pressure. No other focal neurological symptoms or systemic concern were noted. Physical examination revealed right-sided upper motor neuron facial paresis, nonfluent aphasia, dysarthria. His baseline National Institutes Health Scale score was 4. signs meningeal irritation Noncontrast computerized tomography the head a hypodensity in left temporoparietal region suggestive an infarct, along chronic infarcts right cerebellum, parietal lobe, thalamus. In addition, multiple hyperdense areas (largest being perisylvian region) observed supratentorial regions as well (Figure 1A 1B). Computed angiography vessels followed conventional digital subtraction cerebral dysplastic/fusiform aneurysms, 3 involving pericallosal artery, distal middle artery M4 branches, 1 callosomarginal 1C). The inferior branch dysplastic partially thrombosed proximal aneurysm fusiform 1D). Contrast-enhanced magnetic resonance imaging brain confirmed presence infarct largest sylvian fissure measuring 13 mm 2A through 2D). There parenchymal structural lesions macro hemorrhages. Hematology investigations unremarkable. A transthoracic echocardiogram performed, which large mobile mass 1.8×3.1 cm calcific rim echo lucent space its substance, attached on atrial side anterior mitral valve limited attachment interatrial septum. evidence systolic dysfunction observed. differential diagnosis entertained view clinical, neuroimaging, cardiac findings intracardiac tumor-like myxoma versus infective noninfective endocarditis. high-risk cardioembolic source, patient deemed be candidate early surgical resection lesion, duly performed within week hospitalization. Postoperative histopathologic resected pathology consistent 3A 3B). intraoperative postprocedural complications aneurysms multiple, unruptured, secondary underlying myxoma, not subjected open surgery endovascular embolization. Plan potential combined chemoradiotherapy intervention will discussed based follow-up angiographic studies. maintained single antiplatelet agent stroke prophylaxis, advice speech language rehabilitation his residual deficits.Download figureDownload PowerPointFigure 1. tomography. showing axial images (A) (thick arrow); (A; thin arrow) posterior subcortical frontal (B; arrow). C, Invasive angiogram internal depicting (arrow head), (star thick arrow), (MCA; D, Lateral projection views depict MCA (thin arrow).Download 2. brain. isointense circumferential precontrast T1 images. B, T2 sections reveal hypointense signal mixed intense lesion is susceptibility weighted sequences (C; exhibits enhancement vessel wall (MCA) (D; nodular contrast-enhanced coronal sequences. insular MCA. there territory star).Download 3. Hematoxylin eosin staining. staining tissue low power shows blue background acid mucopolysaccharides mesenchymal cells (depicted green circles), high (B) demonstrating round, plump, stellate myxoma.DiscussionCardiac most common primary tumor, accounting up 80%, estimated annual incidence 0.5 per million population year.1–3 More than 80% myxomas arise from atrium,2 multitude presentations form obstructive symptoms, embolization (cerebral and/or systemic) constitutional symptoms.1–3 Fifty percentage patients present related obstruction (dyspnea, dizziness, palpitations, congestive heart failure) can occur 70% them during natural course illness.2 Constitutional fever, weight loss, fatigue may about 58% those myxoma. Systemic noted one-third cases at any time illness.1–3 have been documented 26% 45% myxomas.2 commonly ischemic infarcts1,2 rarely myxomatous metastases, intracerebral hemorrhage.3–5 Transthoracic echocardiography gives initial clue toward mass, transesophageal echocardiogram) providing further details location mobility, especially small-sized biatrial tumors.6,7 However, neither abovementioned techniques are helpful differentiate tumors thrombi.7 Multimodality has played vital role reliably diagnosing preoperatively. Cardiac heterogenous hypointensity relative myocardium, hyperintensity, contrast imaging, unique compared thrombus.7 Surgical definitive treatment option medical management even anticoagulant therapy proven ineffective prevent recurrent embolic events.2,6 As development phenomenon sudden death ?10% awaiting surgery, should considered emergency, avoidance delays without obvious contraindications.6,7 Despite lack global consensus ideal procedure resection, in-hospital mortality seldom exceeds 3% available literature evidence,6 thereby contributing excellent mid-term results if promptly. Antiplatelets anticoagulants (Warfarin) traditionally used both pre- postcardiac (for variable duration), clear evidence-based guidelines recommendations now.1,2To date, fewer 60 published literature, first 1966,2,8 ones rarer. Rarity entity contributed knowledge evolution turn leading definite well.8–10 Our that he had simultaneous neuroimaging manifestations embolization, include commoner less aneurysms.3 latter often delayed complication mean between tumor detection varying 300 months.3,4,8 review 37 median age 38 years (range, 10–69 years), female:male ratio 2.7:1.10 These usually fusiform/saccular morphology predilection branches arteries.2,3 Advancements modalities better delineation identification metastases.4,5 On noncontrast brain, these seem hyperdense, account accumulation myxoid matrix calcification aneurysmal wall.10 Although exact mechanism still enigmatic, plausible accepted one metastasize infiltrate theory, whereby fragments embolize heart, seed wall, initiate inflammatory cascade, in-turn dilatation formation.1–3,8,10 High levels interleukin-6 CSF produced contribute upregulation MMPs (matrix metalloproteinases), promotes degradation extracellular invasion into walls arteries, ultimately resulting formation.3,10 This theory substantiated demonstration proliferation elastic lamina.10 An alternative hypothesis pathogenesis damage postembolic subsequent endothelial scarring contributes hemodynamic alteration dynamics formation.10Take-Home PointsCardiac notorious manifestations.Ischemic manifestation 0.5% all strokes attributed embolization.Myxomatous metastases rarer myxomas, putative pathological theory.Mobility rather size determines potential.Concomitant make suspect possibility despite rare entity.On rarity cases, little history aneurysms. meta-analysis highlighted 78.4% managed conservatively, 75.9% among stability regression studies.10 Hence unruptured majority researchers propose conservative management, serial studies (initially months later 6–12 interval stability), look change, enlargement. About 20.7% study Zheng et al10 demonstrated enlargement studies, all-cause 3.4%. paucity data rupture cases. cannot extrapolated different respective mechanisms involved.There isolated reports pertaining microsurgical resection/endovascular coiling,8 chemotherapy, radiotherapy9 although guideline lacking. case ruptured enlarging aneurysm, decision treat made basis. Given times involve terminal vessels, their limitations assure complete cure. Open microsurgery trapping aneurysm. Application clips feasible given friable nature wall. Standard coil possible invaded remain unattended treatments, potentially recurrence.8 antithrombotic medications after myxomas. actively proliferating chemotherapy (doxorubicin/etoposide/carboplatin) radiotherapy effective individual cases.9,10On foci active hemorrhage our planned assess evolution, bypass (left artery) new symptoms.ConclusionsCardiac manifest de novo presentation latter, protocols unclear might completely occurrence metastases.Sources FundingNone.DisclosuresNone.FootnotesFor Sources Funding Disclosures, see page e13.Correspondence protected]aeReferences1. Desousa AL, Muller J, Campbell R, Batnitzky S, Rankin L. Atrial myxoma: complications, recurrences.J Neurol Neurosurg Psychiatry. 1978; 41:1119–1124. doi: 10.1136/jnnp.41.12.1119CrossrefMedlineGoogle Scholar2. Lee VH, Connolly HM, Brown RD. Central nervous system myxoma.Arch Neurol. 2007; 64:1115–1120. 10.1001/archneur.64.8.1115CrossrefMedlineGoogle Scholar3. 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Branscheidt Frontzek K, Bozinov O, Valavanis Rushing EJ, Weller Wegener Etoposide/carboplatin metastatic 2014; 261:828–830. 10.1007/s00415-014-7281-3Google Scholar10. Li Cao Zhao J. what optimal treatment?J Cerebrovasc 2015; 24:232–238. doi:10.1016/j.strokecerebrovasdis.2014.08.017.Google Scholar Previous Back top Next FiguresReferencesRelatedDetails January 2021Vol Issue 1Article InformationMetrics Download: 2,293 © 2020 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.120.031679PMID: 33213289 publishedNovember 20, Keywordsdysarthriarisk factorsmalespeechheadachePDF download SubjectsIschemic StrokeVascular DiseaseCerebrovascular Disease/StrokeCerebral AneurysmThrombosis