Delayed multiple hemorrhagic brain metastases from atrial myxoma: a case report and literature review

Objective: Brain metastases from atrial myxoma are rare central nervous system manifestations and may mimic hemorrhagic malignant metastases or vascular lesions. We report a delayed case after prior cardiac myxoma resection and summarize the available patient-level literature. Methods: We retrospectively reviewed the clinical course, multimodal neuroimaging, surgical findings, histopathology, immunohistochemistry, vascular imaging, and follow-up of a woman in her early 70s. A literature review was performed using PubMed, Web of Science, Embase, and Google Scholar from inception to 19 June 2026 with search terms related to cardiac/atrial myxoma, brain/intracranial metastasis, brain metastases, implantation, and cerebral aneurysm. Cases with histologically confirmed intracranial parenchymal myxomatous lesions were included. Results: The patient presented with recurrent dizziness, gait instability, right-sided weakness, and incomplete homonymous hemianopia. Brain lesions were detected 5 months after surgical resection of a left atrial myxoma, and echocardiography showed no local recurrence of the cardiac tumor. Brain CT and MRI demonstrated multiple hemorrhagic enhancing lesions with perilesional edema involving the cerebellar vermis, left occipital lobe, and other cerebral and cerebellar regions. Preoperative CTA showed no suspicious intracranial aneurysm. Two representative symptomatic lesions were surgically removed because of diagnostic uncertainty and local mass effect, whereas the remaining multifocal hemorrhagic lesions were managed with close radiological surveillance. Histology showed spindle/stellate cells in abundant myxoid stroma, and immunohistochemistry was positive for calretinin and CD31 but negative for GFAP and desmin, supporting brain metastases from atrial myxoma. At 6-month follow-up, MRI showed no local recurrence and repeat CTA showed no suspicious aneurysm. Conclusion: Delayed hemorrhagic brain metastases from atrial myxoma should be considered when patients with a history of cardiac myxoma develop new neurological symptoms and multiple hemorrhagic enhancing brain lesions. Diagnosis requires integration of clinical history, neuroimaging, vascular imaging, radiology-pathology correlation, and immunohistochemistry. Treatment and surveillance should be individualized because embolic stroke, myxomatous aneurysms, and parenchymal metastases may coexist and recurrence can occur after long latency.