Delayed intracranial lesions following cardiac myxoma resection in a patient with concurrent cerebral embolism: a diagnostic challenge in the absence of pathological evidence

Background: Cardiac myxoma is the most common primary benign cardiac tumor and a known cause of cerebral embolism due to tumor fragment embolization. However, long-term intracranial imaging findings following surgical resection of cardiac myxoma are rarely documented. Case summary: We report a 56-year-old female with a history of intracranial aneurysm intervention, hospitalized for acute cerebral infarction. Transthoracic echocardiography (TTE) revealed a cardiac mass, which was resected and pathologically confirmed as benign cardiac myxoma. Ten months postoperatively, she developed limb convulsive seizures meeting criteria for acute symptomatic seizures. Cranial MRI with DWI showed new-onset multiple nodular hemorrhagic lesions, and PET-CT suggested myxoma recurrence with metastatic infiltration. The case was discussed at a multidisciplinary team (MDT) meeting involving neuro-oncology, neurosurgery, interventional radiology, and cardiology, At 16 months postoperatively, imaging revealed increased number and size of intracranial metastases, with worsening edema and midline shift. After full counseling, the patient and her family declined radiotherapy and biopsy. Thus, the diagnosis was based on imaging and clinical correlation, without pathological confirmation. Conclusion: This case highlights the diagnostic challenges in differentiating intracranial lesions following cardiac myxoma resection and underscores the importance of long-term cranial imaging surveillance. Even after complete tumor resection, clinicians should remain vigilant for potential myxoma-related complications.