Cardiac myxoma and ischemic stroke

Cardiac myxoma is a rare etiology of cardioembolic stroke. We report a case of intra-arterial tirofiban administration in a patient with acute ischemic stroke due to left atrial myxoma. Our purpose is to increase awareness at evaluation of secondary causes of ischemic stroke and provide a treatment option. Cardiac myxoma, which is most commonly found in the left atrium, is a rare etiology of cardioembolic stroke.1 The diagnosis of cardiac myxoma is seldom found at the onset of cerebral embolism when considering emergency endovascular treatment. We present a case of a 52-year-old Chinese male who had an ischemic stroke caused by left atrial myxoma, followed by an obvious recovery after treatment with intra-arterial tirofiban administration. A 52-year-old man was admitted to the emergency department on the 11th of December in 2018, due to right-side hemiplegia accompanied with aphasia for a 3-h history of acute onset. On emergency department arrival, his initial blood pressure was 135/79 mmHg and heart rate was 72 beats/min and regular, with no pathological murmurs in all heart valve auscultation areas, and blood sugar was within normal range. At the neurological evaluation, the patient was awake, unable to follow our commands. His National Institutes of Health Stroke Scale (NIHSS) score was 18. There was no hemorrhage or mass effect on his head computed tomography scan, and the most likely diagnosis was considered to be ischemic stroke. His family consented to direct endovascular treatment without intravenous rtPA treatment, understanding the risk of neurologic worsening and death. Emergency angiography revealed slowed blood flow at the branch of the left middle cerebral artery (LMCA) M2. 5F single-bend catheter was sent to the left internal carotid artery C1 segment, and local intra-arterial antithrombotic therapy with 0.5 mg tirofiban was administered. Ten minutes later, subsequent angiography demonstrated that the blood flow velocity of LMCA is significantly faster than before. Interestingly, we could see that there are multiple small emboli attached with contrast agent in the cerebral blood vessels from the angiography (Figure 1a). Admission brain magnetic resonance imaging revealed multiple cerebral infarctions in bilateral cerebral hemisphere, cerebellar hemisphere and right dorsal thalamus. Transthoracic echocardiogram showed left atrial mass, considered the possibility of myxoma. (a) Angiography shows multiple small emboli (red arrow) attached with contrast agent in the cerebral blood vessels. (b) Histology of resected myxoma tissue. The patient was recovering well with an NIHSS score of 4 and arranged to discharge 12 days after the stroke. He underwent an excision of the myxoma in cardiothoracic surgery department of our hospital on the 25th of January in 2019. The mass was 3.5 cm × 2.5 cm × 1.5 cm and pathological analysis revealed it to be a myxoma (Figure 1b). On 1-year follow-up, he had only residual dysarthria and difficulty in accessing words, and no recurrent ischemic events. As per our literature search, this is the first case of intra-arterial tirofiban administration in a patient with left atrial myxoma who present with acute ischemic stroke. The surface of myxoma is smooth and gelatinous. Its texture is extremely brittle and fragile, and it can fall off locally or in pieces. Arterial embolism due to cardiac myxoma can occur in any part of the body, and cerebral ischemia is the most common clinical presentation. The emboli consist of the myxoma tissue, thrombus or composite of both. Intravenous thrombolysis contributes to arterial recanalization in the patients with hyperacute ischemic stroke due to cardiac myxoma.2,3 The effect of thrombolysis depends on the composition of the emboli. When intravenous thrombolysis therapy was not effective, the patients may have a favorable outcome through mechanical thrombectomy4,5 or intra-arterial tirofiban administration. The patient we reported did not experience any symptoms before stroke and had no common stroke risk factors such as hypertension, diabetes, atrial fibrillation, hypercholesterolemia and obesity. No pathological murmurs are heard in his all heart valve auscultation areas. In such patients, the possibility of cardiac myxoma causing ischemic stroke should be highly suspected. Echocardiography is the first choice for the diagnosis of cardiac myxoma. The study was approved by the ethics committee of our hospital. The patient family signed the written informed consent for publication of this case report and his accompanying images. This work was supported by grants from the Research Project of the First Affiliated Hospital of Wannan Medical College (Grant No. YR201604) and the Scientific Research Foundation of Wannan Medical College (Grant No. WK2019F20). The funding sources had no role in the design, collection, analysis or interpretation of data and in writing the manuscript. Conflict of interest: None declared.