Cardiac myxoma should be considered in the differential diagnosis of young patients presenting with embolic stroke, as prompt imaging and surgical excision can lead to successful recovery.
Atrial myxoma is the most common primary cardiac tumour (80%) which has a multitude of clinical presentations, with 30% neurological(1). Although rare, it should be considered as a possibility of stroke in young adults with no relevant past history. The most common differential of left atrial thrombi sometimes confuses with similar presentations and delays the diagnosis due to non-availability of gold standard TEE and biopsy. We present a 25 years old female patient who was a referred to our hospital following complains of sudden onset loss of consciousness and left hemiplegia, in whom we incidentally found out a left atrial mass and managed successfully. CASE REPORT: A 25 years old, thinly built female was referred to our hospital following complains of loss of consciousness (lasting thirty minutes) and left sided weakness for last 6 hours. She underwent ovarian teratoma resection one year back under general anaesthesia which was uneventful. On initial assessment, she was confused, irritable (GCS- E2V1M5, unequal pupils) and unable to move left side of her body. Her initial vitals were heart rate-120/m, BP- 120/60mm of HG, SPO2-90% at room air. In view of low GCS score she was intubated immediately and shifted to radiology. Her CT scan showed right sided temporo-parietal infarct without midline shift. On cardiology evaluation ECG showed marked tachycardia with normal troponin. Trans thoracic Echocardiogram showed mobile rough surfaced polypoid shaped mass attached to the atrial side of the anterior mitral valve and intra atrial septum causing significant mitral stenosis (mean gradient 29 mm HG) along with dilated left atrium. However systolic function was preserved with ejection fraction 50%. Immediate differentials thought were atrial clot, myxoma and vegetations. She was initially managed for acute infarct with mechanical ventilation, anti-epileptics, anti-platelets, anti- coagulants and statins. Daily assessment was done with transthoracic echo of the cardiac mass which maintained its size and shape, shifting differential towards myxoma. Cardiac MRI however favoured more of LA clot as no definite stalk of the mass was clearly visible. She was gradually weaned of ventilation on day 3 with improved GCS and stable vitals but persistent left sided weakness. On day 10 of admission she was taken for excision of cardiac mass under general anaesthesia. Intra operatively a 3cms/2 cms left atrial mass with rough surface and calcified stalk arising from IAS was excised. Surgical defect was repaired with pericardial patch. Histopathology of the excised mass confirmed stellate shaped myxoma cells in myxoid background. Postoperative period was uneventful and she was weaned off ventilator on the next day. She was eventually discharged from hospital on day 15 with fully recovered GCS and improved left motor functions (4/5). DISCUSSIONS: Cardiac myxoma although rare is the most common cardiac tumour, with left side (80%) and 2:1 female predominance (30-60 yrs).(1, 2) It presents with a varied clinical presentations, most likely cardiac (obstructive, embolic, arrythmia) constitutional and neurological sequels (25-40%).(3) Most common neurological complication seen in the form of brain infarct (83%) due to detached thrombus from the primary mass. About 7% of patients are present as a part of Carneys complex showing autosomal dominant mutation of PRKAR1 alpha gene located on chromosome 17q.(4) Due to the varied clinical features and rare incidence diagnosis may be missed, increasing mortality and morbidity. Echocardiography and neurological tests are of prime importance in young patients with embolic symptoms. Although Trans thoracic echocardiography identifies the mass, Trans-esophageal echocardiography is 100% sensitive if available. Cardiac MRI however gives a better idea of the myxoma regarding stalk, size, shape and surgical planning. Brain infarct although needs immediate anticoagulation, but it may delay more definitive treatable cardiac cause. Stroke may be embolic or hemorrhagic with varied clinical features ranging from focal deficits to massive CNS insults. As stroke may be recurrent due to dislodgement of the tumour or adherent thrombus, anticoagulants may not be protective(5). Most cardiac myxomas are surgically resectable with recurrence rate of 3% in sporadic and 25% in Carney complex patients, requiring regular cardiac screening.(4) CONCLUSION: Although rare, cardiac myxoma should be ruled out in young patients with embolic stroke by prompt imaging, quick management to decrease mortality and morbidity. In our presented patient, cardiology workup was done to find out the source of embolic stroke causing sudden unilateral hemiparesis which lead us to diagnose and manage atrial myxoma.
Abhishek Biswas (Thu,) studied this question.