Stroke of a cardiac myxoma origin

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.

Descriptors:
Embolism; Middle Cerebral Artery; Myxoma; Stroke

Abbreviations, acronyms & symbols
CT	Computed tomography
MRI	Magnetic resonance imaging

Neurological symptom	n (%)
Hemiparesis	51 (49.0)
Aphasia	29 (27.9)
Conscious alteration	24 (23.1)
Hemiplegia	18 (17.3)
Dysarthria	17 (16.3)
Ataxia	11 (10.6)
Vision disturbance	10 (9.6)
Dysesthesia	9 (8.7)
Seizures	7 (6.7)
Collapse	6 (5.8)
Dizziness	6 (5.8)
Dysphagia	4 (3.8)
Hemianopsia	4 (3.8)
Mental disturbance	4 (3.8)
Transient ischemic attack	4 (3.8)
Vertigo	4 (3.8)
Diplopia	3 (2.9)
Facial paresis	3 (2.9)
Disorientation	2 (1.9)
Syncope	2 (1.9)
Nausea/vomiting	2 (1.9)
Cognitive impairment	1 (10)
Convulsion	1 (10)
Epilepsy	1 (10)
Hypomnesis	1 (10)
Memory loss	1 (10)
Paraparesis	1 (10)
Ptosis	1 (10)
Quadriparesis	1 (10)

Risk factor	n (%)
Hypertension	13 (9.8)
Hyperlipidemia	5 (3.8)
Smoking	5 (3.8)
Atrial fibrillation	4 (3.0)
Coronary artery disease	4 (3.0)
Hypertension, hyperlipidemia	3 (2.3)
Hypertension, diabetes mellitus	2 (1.5)
Alcohol	1 (0.8)
Mitral regurgitation	1 (0.8)
Neurosurgery for temporooccipital cavernoma	1 (0.8)
Raynaud's disease	1 (0.8)
Transient ischemic attack	1 (0.8)
Unknown	1 (0.8)

Diagnostic tool	n (%)
MRI	39 (48.1)
CT	23 (28.4)
CT, MRI	7 (8.6)
MRI, MRA	4 (4.9)
MRA	3 (3.7)
Autopsy	1 (1.2)
CT, MRA	1 (1.2)
CT, MRI, angiogram	1 (1.2)
Computed tomographic angiography	1 (1.2)
MRI, autopsy	1 (1.2)

Computed tomography	Initial	Subsequent
Positive	5 (26.3)	40 (87.0)
Negative	14 (73.7)	6 (13.0)
χ²	8.5	50.3
P value	0.009	0.000

Affected cerebral artery		n (%)
MCA		35 (64.8)
	Left	21 (60)
	Right	12 (34.3)
	Unknown	2 (5.7)
Internal carotid artery		6 (11.1)
Posterior cerebral artery		3 (5.6) [1 (33.3) with aneurysm and 1 (33.3) with stenosis)]
Basilar artery		2 (3.7)
MCA, anterior cerebral artery		2 (3.7)
Internal carotid artery + vertebrobasal artery		1 (19)
MCA, posterior inferior cerebellar artery		1 (19)
MCA, posterior cerebral artery		1 (19)
MCA, basilar artery		1 (19)
Posterior inferior cerebellar artery		1 (19)
Superior cerebellar artery		1 (19)

Location of infarct	n (%)
Basal ganglion	28 (45.2)
Cerebellum	23 (37.1)
Parietal	17 (27.4)
Temporal	12 (19.4)
Cerebral	10 (16.1)
Frontal	9 (14.5)
Occipital	9 (14.5)
Capsula interna	7(11.3)
Thalamic	6 (9.7)
Frontoparietal	5 (8.1)
Brainstem	3 (4.8)
Lacunar	3 (4.8)
Pons	3 (4.8)
Corpus callosum	2 (3.2)
Corona radiate	1 (16)
Frontotemporal	1 (16)
Insular cortex	1 (16)
Medulla	1 (16)
Perisylvian	1 (16)
Periventricular	1 (16)
Sylvian fissure	1 (16)
Watershed	1 (16)

Infarct side	Single	Multiple	χ²	P value
Left	15 (39.5)	14 (22.6)	0.069	1.000
Right	14 (36.8)	6 (9.7)	6.40	0.026
Bilateral	--	26 (41.9)	--	--
Not given	9 (23.7)	16 (25.8)	3.92	0.089
Total	38 (100)	62 (100)	11.52	0.001

Affected artery		n (%)	Reference
Extremity artery		14 (35.9)
	Brachial	1 (7.1)	^[ ⁷²72. Singh PK, Sureka RK, Sharma AK, Bhuyan S, Gupta V. Recurrent stroke in a case of left atrial myxoma masquerading vasculitis. J Assoc Physicians India. 2013;61(12):912, 917-20. ^]
	Radial	1 (7.1)	^[ ⁷²72. Singh PK, Sureka RK, Sharma AK, Bhuyan S, Gupta V. Recurrent stroke in a case of left atrial myxoma masquerading vasculitis. J Assoc Physicians India. 2013;61(12):912, 917-20. ^]
	Ulnar	1 (7.1)	^[ ⁷²72. Singh PK, Sureka RK, Sharma AK, Bhuyan S, Gupta V. Recurrent stroke in a case of left atrial myxoma masquerading vasculitis. J Assoc Physicians India. 2013;61(12):912, 917-20. ^]
	Dorsalis pedis	1 (7.1)	^[ ⁸⁵85. Yuan SM. Prognostic prediction of troponins in cardiac myxoma: case study with literature review. Rev Bras Cir Cardiovasc. 2015;30(2):276-82. ^]
	Peroneal	1 (7.1)	^[ ⁷²72. Singh PK, Sureka RK, Sharma AK, Bhuyan S, Gupta V. Recurrent stroke in a case of left atrial myxoma masquerading vasculitis. J Assoc Physicians India. 2013;61(12):912, 917-20. ^]
	Popliteal	2 (14.2)	^[ ⁸⁰80. Vogel B, Thomas D, Mereles D, Rottbauer W, Katus HA. Systemic embolization and myocardial infarction due to clinically unrecognized left atrial myxoma. Case Rep Med. 2011;2011:159024. ^]
	Tibial	2 (14.2)	^[ ⁷²72. Singh PK, Sureka RK, Sharma AK, Bhuyan S, Gupta V. Recurrent stroke in a case of left atrial myxoma masquerading vasculitis. J Assoc Physicians India. 2013;61(12):912, 917-20. ^, ⁸⁵85. Yuan SM. Prognostic prediction of troponins in cardiac myxoma: case study with literature review. Rev Bras Cir Cardiovasc. 2015;30(2):276-82. ^]
	Tibio-peroneal trunk	1 (7.1)	^[ ⁷²72. Singh PK, Sureka RK, Sharma AK, Bhuyan S, Gupta V. Recurrent stroke in a case of left atrial myxoma masquerading vasculitis. J Assoc Physicians India. 2013;61(12):912, 917-20. ^]
	Unknown	4 (28.6)	^[ ¹³13. Alvarez-Sabín J, Lozano M, Sastre-Garriga J, Montoyo J, Murtra M, Abilleira S, et al. Transient ischaemic attack: a common initial manifestation of cardiac myxomas. Eur Neurol. 2001;45(3):165-70. ^, ⁷⁶76. Uner A, Dogan M, Sal E, Peker E. Stroke and recurrent peripheral embolism in left atrial myxoma. Acta Cardiol. 2010;65(1):101-3. ^, ⁸⁴84. Yoshioka D, Takahashi T, Ishizaka T, Higuchi T. Successful surgical resection of infected left atrial myxoma in a case complicated with disseminated intravascular coagulation and multiple cerebral infarctions: case report. J Cardiothorac Surg. 2011;6:68. ^]
Visceral artery		13 (23.1)
	Hepatic	1 (7.7)	^[ ⁶³63. Pearce AW, Rana BS, O'Donovan DG. Lesson of the month. (2). Stroke in a 53-year-old woman: getting to the heart of the problem. Diagnosis. LA myxoma. Clin Med. 2013;13(1):106-9. ^]
	Mesenteric	2 (15.4)	^[ ¹⁶16. Bajraktari G, Emini M, Berisha V, Gashi F, Beqiri A, Zahiti B, et al. Giant left atrial myxoma in an elderly patient: natural history over a 7-year period. J Clin Ultrasound. 2006;34(9):461-3. ^, ⁸⁰80. Vogel B, Thomas D, Mereles D, Rottbauer W, Katus HA. Systemic embolization and myocardial infarction due to clinically unrecognized left atrial myxoma. Case Rep Med. 2011;2011:159024. ^]
	Renal	3 (23.1)	^[ ⁵⁵55. Nicholls GM, Clearwater G. Emergency presentation of emboli to multiple sites from an atrial myxoma. Emerg Med Australas. 2012;24(3):336-8. ^, ⁶³63. Pearce AW, Rana BS, O'Donovan DG. Lesson of the month. (2). Stroke in a 53-year-old woman: getting to the heart of the problem. Diagnosis. LA myxoma. Clin Med. 2013;13(1):106-9. ^, ⁸⁰80. Vogel B, Thomas D, Mereles D, Rottbauer W, Katus HA. Systemic embolization and myocardial infarction due to clinically unrecognized left atrial myxoma. Case Rep Med. 2011;2011:159024. ^]
	Splenic	3 (23.1)	^[ ⁵⁵55. Nicholls GM, Clearwater G. Emergency presentation of emboli to multiple sites from an atrial myxoma. Emerg Med Australas. 2012;24(3):336-8. ^, ⁶³63. Pearce AW, Rana BS, O'Donovan DG. Lesson of the month. (2). Stroke in a 53-year-old woman: getting to the heart of the problem. Diagnosis. LA myxoma. Clin Med. 2013;13(1):106-9. ^, ⁸⁰80. Vogel B, Thomas D, Mereles D, Rottbauer W, Katus HA. Systemic embolization and myocardial infarction due to clinically unrecognized left atrial myxoma. Case Rep Med. 2011;2011:159024. ^]
Coronary		4 (10.3)
	Circumflex	1 (25)	^[ ⁴¹41. Konagai N, Cho M, Shigematsu H. Left atrial myxoma associated with acute myocardial infarction and multiple cerebral infarctions: report of a case. Surg Today. 2010;40(12):1159-63. ^]
	Ramus intermedius	1 (25)	^[ ³⁵35. Jeon U, Cho YS, Kim DH, Park SH, Lee SJ, Shin WY, et al. Probable left atrial myxoma presenting as concurrent cerebral and myocardial infarctions. Korean Circ J. 2008;38(11):622-6. ^]
	Unknown	2 (50)	^[ ⁶³63. Pearce AW, Rana BS, O'Donovan DG. Lesson of the month. (2). Stroke in a 53-year-old woman: getting to the heart of the problem. Diagnosis. LA myxoma. Clin Med. 2013;13(1):106-9. ^, ⁸⁰80. Vogel B, Thomas D, Mereles D, Rottbauer W, Katus HA. Systemic embolization and myocardial infarction due to clinically unrecognized left atrial myxoma. Case Rep Med. 2011;2011:159024. ^]
Other peripheral artery		8 (20.5)
	Carotid	3 (37.5)	^[ ¹¹11. Al-Said Y, Al-Rached H, Baeesa S, Kurdi K, Zabani I, Hassan A. Emergency excision of cardiac myxoma and endovascular coiling of intracranial aneurysm after cerebral infarction. Case Rep Neurol Med. 2013;2013:839270. ^, ¹⁹19. Binning MJ, Sarfati MR, Couldwell WT. Embolic atrial myxoma causing aortic and carotid occlusion. Surg Neurol. 2009;71(2):246-9. ^, ⁶³63. Pearce AW, Rana BS, O'Donovan DG. Lesson of the month. (2). Stroke in a 53-year-old woman: getting to the heart of the problem. Diagnosis. LA myxoma. Clin Med. 2013;13(1):106-9. ^]
	Femoral	2 (25)	^[ ²¹21. Silva IR, de Freitas GR. Is it safe to proceed with thrombolytic therapy for acute ischemic stroke in a patient with cardiac myxoma? Case report and review of the literature. Eur Neurol. 2012;68(3):185-6. ^, ⁸⁰80. Vogel B, Thomas D, Mereles D, Rottbauer W, Katus HA. Systemic embolization and myocardial infarction due to clinically unrecognized left atrial myxoma. Case Rep Med. 2011;2011:159024. ^]
	Iliac, internal	2 (25)	^[ ⁵⁵55. Nicholls GM, Clearwater G. Emergency presentation of emboli to multiple sites from an atrial myxoma. Emerg Med Australas. 2012;24(3):336-8. ^, ⁸⁰80. Vogel B, Thomas D, Mereles D, Rottbauer W, Katus HA. Systemic embolization and myocardial infarction due to clinically unrecognized left atrial myxoma. Case Rep Med. 2011;2011:159024. ^]
	Retinal	1 (12.5)	^[ ⁹9. Al Ali A, Al Shawaf H, Al Khalaf Y. Stroke caused by left ventricular myxoma. J Am Coll Cardiol. 2011;57(6):e11. ^]
Great vessel		4 (10.3)
	Abdominal aorta	2 (50)	^[ ⁶⁰60. Ohgo T, Yamamoto K, Furuno T. Complete detachment of cardiac myxoma causing aortic saddle embolization and cerebral infarction. Int J Cardiol. 2008;127(2):e48-9. ^, ⁸⁰80. Vogel B, Thomas D, Mereles D, Rottbauer W, Katus HA. Systemic embolization and myocardial infarction due to clinically unrecognized left atrial myxoma. Case Rep Med. 2011;2011:159024. ^]
	Infrarenal aorta	1 (25)	^[ ¹⁹19. Binning MJ, Sarfati MR, Couldwell WT. Embolic atrial myxoma causing aortic and carotid occlusion. Surg Neurol. 2009;71(2):246-9. ^]
	Pulmonary	1 (25)	^[ ⁴³43. Landers C, Baumann R, Cottrill CM. Embolic strokes in an 8-year-old girl. Neurology. 2000;55(1):146. ^]

Diagnostic means	n (%)
TTE	79 (69.3)
TTE, TEE, 3D TEE	12 (10.5)
TEE	9 (7.9)
TTE, MRI	4 (3.5)
Autopsy	3 (2.6)
Computed tomography, TTE	2 (1.8)
TTE, TEE, MRI	2 (1.8)
Computed tomography, TTE, TEE	1 (0.9)
Computed tomography angiography, TTE	1 (0.9)

Location		n (%)
Single		105 (93.8)
	LA	93 (88.6)
	LV	8 (7.6)
	Left heart	1 (10)
	Atrium	1 (10)
	Infrarenal aorta (complete detachment to)	1 (10)
	RA	1 (10)
Multiple		7(6.3)
	LA, RA	2 (28.6)
	LA, LV, RA, RV	1 (14.3)
	Multiple chambers	1 (14.3)
	LA, pulmonary vein orifice, mitral annulus	1 (14.3)
	LA, mitral annulus	1 (14.3)
	LA, RV	1 (14.3)

Surgical operation		n (%)
Isolated myxoma resection		82 (83.7)
Myxoma resection with concurrent heart operation		8 (8.2)
	Mitral valve repair	3 (37.5)
	Mitral valve replacement	1 (12.5)
	Aortic valve replacement	1 (12.5)
	Patent fossa ovalis/atrial septal defect closure	2 (25)
	Coronary artery bypass grafting	1 (12.5)
Myxoma resection with other operation		6 (6.1)
	Peripheral embolectomy	2 (33.3)
	Peripheral embolectomy and amputation	1 (16.7)
	Peripheral embolectomy, fasciotomies and amputation	1 (16.7)
	Decompression craniotomy	1 (16.7)
	Endovascular coiling of internal carotid artery aneurysm	1 (16.7)
No myxoma resection		2 (2.0)
	Embolectomies and herniation decompressive hemicraniectomy	1 (50)
	Cranial decompression	1 (50)

Authors' roles & responsibilities
SMY	Main Author
GH	Final approval of the manuscript

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[1] Correspondence address: Shi-Min Yuan, Longdejing Street, 389 - Chengxiang District, Putian, Fujian Province, People's Republic of China. E-mail: shi_min_yuan@yahoo.com