Delayed diagnosis of recurrent embolic strokes from cardiac myxoma coexisting with antiphospholipid syndrome presenting as progressive cognitive decline

A woman in her 40s presented with progressive cognitive decline, expressive language difficulty and episodic confusion. Her initial symptoms were misattributed to psychiatric illness, and later to small vessel ischaemia, delaying appropriate evaluation. Over 2 years, serial MRIs revealed multiple new cortical infarcts. Stroke workup confirmed antiphospholipid syndrome (APS) yet continued concern for a persistent embolic source prompted trans-oesophageal echocardiography, which revealed a mass on the posterior mitral leaflet. Surgical excision confirmed a benign cardiac myxoma with no further embolic events on follow-up. This case illustrates how neuro-embolic events can manifest as non-specific psychiatric or cognitive symptoms, and how early assumptions may delay appropriate diagnosis. Even after diagnosing a prothrombotic condition like APS, clinicians must look for structural cardiac lesions that may coexist and amplify embolic risk. Comprehensive aetiological assessment is essential in embolic stroke of undetermined source, especially in younger patients with atypical presentations.