Heart or head?: A depression mimic delays diagnosis—oncotic cerebral aneurysms caused by atrial myxoma

Figures

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  Figure 1.. Non-contrast CT brain demonstrating bilateral supratentorial hyperdense punctate haemorrhagic foci. The largest lesion was infratentorial, in the right cerebellar hemisphere (depicted on MRI images).

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  Figure 2.. Maximum intensity projection susceptibility weighted image sequence (mIP SWI) MRI demonstrating haemosiderin deposition in the cerebral sulci.

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  Figure 3.. Non-contrast T1 (left) and T2 (right) images at the level of an irregular ring- like lesion in the right cerebellar hemisphere. The lesion demonstrates low T1 signal and high T2 signal, compatible with a metastasis. Classically a melanoma deposit would demonstrate high T1 signal. Hyperintense T1 and T2 material surrounding the lesion is in keeping with subacute haemorrhage. Note the additional site of haemorrhage in the inferior right occipital lobe, seen on the sagittal slice.

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  Figure 4.. Post contrast T1 weighted stealth MRI sequence demonstrating bilateral enhancing cerebellar lesions and an avidly enhancing aneurysm arising adjacent the posterior wall of the fourth ventricle (arrow). The lesions are suspicious for metastases.

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  Figure 5.. Post contrast, non-gated staging CT Chest showing a left atrial mass, concerning for cardiac myxoma.

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  Figure 6.. Digital subtraction angiography confirming aneurysm formation. The largest aneurysm is located in a peripheral branch of the right anterior cerebral artery (highlighted by arrow).

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  Figure 7.. DSA images of the left vertebral artery. There is extensive background fusiform vessel irregularity. The arrows highlight multiple sites of small aneurysm formation.

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  Figure 8.. Cine SSFP 2-chamber and 4-chamber views demonstrating the left atrial myxoma (see arrows), which is hyperintense relative to the myocardium and hypointense relative to the blood pool. The attachment stalk, difficult to appreciate on a static image, becomes apparent with cardiac motion. SSFP, Steady-state free procession.

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  Figure 9.. Dark Blood T1 (left) and T2 fat-suppressed (right) 2- chamber sequences demonstrate intermediate signal intensity, and hyperintensity, of the myxoma respectively (myxoma highlighted by arrows).

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  Figure 10.. First pass perfusion imaging (left) allows bright gadolinium contrast to clearly outline the mass. Delayed contrast 4-chamber view (right) shows heterogeneous enhancement of the mass (see arrows). The internal non-enhancing area likely corresponds with a region of necrosis.