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      A case of large atrial myxoma presenting as an acute stroke

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          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.

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          Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases.

          P Duhaut, L Pinede, R Loire (2001)
          We analyzed a series of 112 consecutive cases of left atrial myxoma diagnosed in a single French hospital (72 women and 40 men; age range, 5-84 yr) over 40 years, from 1959 to 1998. Symptoms of mitral valve obstruction, the first arm of the classic triad of myxoma presentation, were present in 75 patients (67%), with mostly cardiac failure or malaise. Symptoms of embolism, the second frequent presentation in the classic triad, were observed in 33 cases (29%) with 1 or several locations, essentially cerebral emboli with stroke. Males are statistically at greater risk than females of developing embolic complications. The third arm of the classic triad consists of constitutional symptoms (34%) with fever, weight loss, or symptoms resembling connective tissue disease, due to cytokine (interleukin-6) secretion. Younger and male patients have more neurologic symptoms, and female patients have more systemic symptoms. Seventy-two patients (64%) had cardiac auscultation abnormalities, essentially pseudo-mitral valve disease (53.5%) and more rarely the suggestive tumor plop (15%). The most frequent electrocardiographic sign was left atrial hypertrophy (35%), whereas arrhythmias were uncommon. The greater number of myxoma patients (98) diagnosed preoperatively after 1977 reflects the introduction of echocardiography as a noninvasive diagnostic procedure. However, there was no significant reduction in the average time from onset of symptoms to operation between patients seen in the periods before and after 1977. The tumor diameter ranged from 1 to 15 cm with a weight of between 15 and 180 g (mean, 37 g). The myxoma surface was friable or villous in 35% of the cases, and smooth in the other 65% cases. Myxomas in patients presenting with embolism have a friable surface; those in patients with cardiac symptoms, pseudo-mitral auscultation signs, tumor plop, and electrocardiogram or radiologic signs of left atrium hypertrophy and dilatation are significantly the larger tumors. The long-term prognosis is excellent, and only 4 deaths occurred among our 112 cases over a median follow-up of 3 years. The recurrence rate is low (5%), but long-term follow-up and serial echocardiography are advisable especially for young patients.
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            Neurological manifestations of cardiac myxoma: a review of the literature and report of cases.

            E Ekinci, G Donnan (2004)
            Cardiac myxoma is a rare but important cause of stroke, which affects young people. More recently the diagnosis has been enhanced by the use of echocardiograms. We aimed to review the neurological presentations, including stroke, of cardiac myxoma in this modern era of diagnosis and management. Records of patients with neurological presentations at the Austin and Repatriation Medical Centre and The Northern Hospital were retrieved from 1985 to late 2001, using International Classification of Diseases codes for atrial myxoma. Published literature reports were obtained by using Medline search database. An iterative process of bibliography review was utilised to identify reports not found by primary search. Case demographics, neurological presentations, investigations, treatment and outcome were recorded. From the Austin and Repatriation Medical Centre and The Northern Hospital, 6 cases were reported in detail and 107 cases from the published literature were analysed. The mean age of all cases was 43 (range 6-82). There was a female to male predominance (3:2). While there were overlapping neurological presentations, the most common presentation was ischaemic stroke (83% of all patients) most often in multiple sites (41%). The other presentations included syncope (28%), psychiatric presentations (23%), headache (15%) and seizures (12%). Commonest means of reaching the diagnosis was by echocardiography. The myxoma was surgically resected in 69% of cases. Of all cases, 24% were autopsy reports, almost all prior to availability of echocardiograms (in mid-1970s). Patients who presented with neurological complications of cardiac myxoma were young and stroke was by far the most common single presentation. Importantly, when all clinical manifestations were considered, almost half were potentially reversible. In recent years, echocardiography has made significant contribution to establishing the diagnosis less invasively. There is uncertainty about the role of anticoagulants. The treatment of choice remains surgical excision, although the timing post stroke is debatable. There is a need for large scale collaborative studies to help refine management strategies.
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              Diagnosis of heart tumours by transoesophageal echocardiography: a multicentre study in 154 patients. European Cooperative Study Group.

              W. Daniel Kissling, Adilson Curtius, W Kasper … (1993)
              In a retrospective multicentre study, the diagnostic potential of transoesophageal 2D-echocardiography (TEE) as compared to precordial 2D-echocardiography (TTE) was determined in 154 patients with primary or secondary tumours of the heart. Additionally, the value of standard diagnostic parameters, such as symptoms, X-ray of the chest and electrocardiogram were evaluated. In 84 patients (24 male, 60 female; age 20-85, mean 56.6 years) intracardial tumours were present, and 70 patients (37 male, 33 female; age 18-79, mean 44.3 years) presented with peri- or paracardial tumours. The main symptoms of patients with intracardial tumours were dyspnoea (60.7%), vena cava syndrome (22.2%) and chest pain (20.2%). Embolization was found in 11.9%. Left or right atrial enlargement was observed on chest X-ray in 23 patients, and echocardiographic abnormalities in 17 cases. The patients with peri- or paracardial tumours presented with dyspnoea in 51.4% of cases, loss in body weight in 20.0% and with vena cava syndrome and chest pain in 17.1%. The chest X-ray was abnormal in 56 patients. Unspecific ST segment changes in the electrocardiogram were observed in five, and arrhythmias in seven cases. Diagnosis of atrial myxomas was achieved by TTE in 95.2%, by TEE in 100%, by angiography in 78.4%, by computed tomography (CT) or magnetic resonance tomography (NMR) in 70%. Identification of the attachment point was made by angiography in 8.1%, by TTE in 64.5% and by TEE in 95.2%. In 22 patients with intracardial tumours (myxomas excepted) diagnosis was achieved by TTE in 90.9%, by TEE in 100%, by CT or NMR in 88.9% and by angiography in 50%.(ABSTRACT TRUNCATED AT 250 WORDS)
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Community Hosp Intern Med Perspect
                Journal ID (iso-abbrev): J Community Hosp Intern Med Perspect
                Journal ID (publisher-id): JCHIMP
                Title: Journal of Community Hospital Internal Medicine Perspectives
                Publisher: Co-Action Publishing
                ISSN (Electronic): 2000-9666
                Publication date (Electronic): 17 February 2016
                Publication date Collection: 2016
                Volume: 6
                Issue: 1
                Electronic Location Identifier: 10.3402/jchimp.v6.29604
                Affiliations
                [1 ]Department of Internal Medicine, Seton Hall University of Health and Medical Science at St Francis Medical Center, Trenton, NJ, USA
                [2 ]Department of Neurology, St. Francis Medical Center, Trenton, NJ, USA
                [3 ]Department of Cardiology, St Francis Medical Center, Trenton, NJ, USA
                [4 ]Mercer Bucks Cardiology Group, Robbinsville, NJ, USA
                Author notes
                [* ]Correspondence to: Praneet Iyer, St Francis Medical Center, 601 Hamilton Avenue, Trenton, NJ 08629, USA, Email: iyerpraneet@ 123456yahoo.com
                Article
                Publisher ID: 29604
                DOI: 10.3402/jchimp.v6.29604
                PMC ID: 4763557
                PubMed ID: 26908377
                SO-VID: 584c9d60-f317-4943-b3a5-66621f9deb53
                Copyright © © 2016 Praneet Iyer et al.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 23 September 2015
                Date accepted : 30 November 2015
                Categories
                Subject: Case Report

                Keywords: left atrial myxoma,three-dimensional transesophageal echocardiogram,acute stroke
                Data availability:
                Keywords: left atrial myxoma, three-dimensional transesophageal echocardiogram, acute stroke

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