From cardiac tumor to cerebral hemorrhage: Early multiple hemorrhagic brain metastases after left atrial myxoma resection

Background: Cardiac myxoma is the most common primary benign cardiac tumor and is associated with neurological complications primarily due to embolic phenomena. Although cardiac myxoma is histologically benign, cerebral metastatic dissemination is exceptionally rare and has been described predominantly in isolated case reports and small case series. Case Description: A 46-year-old woman presented with a 2-month history of headache and dizziness, 4 months after surgical excision of a left atrial myxoma. Neurological examination was unremarkable. Brain magnetic resonance imaging (MRI) revealed four heterogeneously enhancing hemorrhagic lesions with surrounding edema and mass effect in the right occipital, right parietal, right superior frontoparietal, and contralateral parieto- occipital regions. The largest lesion, located in the right occipital lobe, measured 48 × 42 mm. Given its size and associated mass effect, surgical excision of the dominant lesion was performed. Histopathological examination demonstrated metastatic cardiac myxoma characterized by myxoid stroma and calretinin positivity, with a low Ki- 67 proliferation index of 1–2%. The postoperative course was uneventful. Following multidisciplinary discussion, whole-brain radiotherapy was administered for the residual multifocal intracranial disease at a total dose of 30 Gy in 10 fractions. At 3-month follow-up, contrast-enhanced MRI of the brain demonstrated a decrease in the size of the residual lesions and no residual enhancing tumor at the resection site. The patient remained neurologically stable without new neurological deficits. Conclusion: Cerebral metastases from cardiac myxoma are exceptionally uncommon and may become apparent months after resection of the primary cardiac tumor. Multiple hemorrhagic intracranial lesions in patients with a history of atrial myxoma should raise suspicion for metastatic disease. Surgical resection may provide tissue diagnosis and decompression of dominant symptomatic lesions, while radiotherapy may be considered in selected patients with multifocal disease. Management should be individualized because evidence supporting specific treatment and surveillance strategies remains limited.