Early and delayed neurological manifestations of cardiac myxomas

Long-term control of haemorrhagic brain metastases from atrial myxoma after radiotherapy

BACKGROUND

Cardiac myxoma is a rare, benign tumour that commonly originates in the left atrium and may lead to embolic events. Parenchymal brain metastases represent a rare neurological manifestation. While surgical intervention is commonly used, there is limited information on long-term outcomes after radiotherapy treatment. This report describes a case of successful treatment of haemorrhagic brain metastases with radiotherapy and offers a literature review of long-term results after radiotherapy treatment.

CASE REPORT

A 49-year-old woman presented with multiple haemorrhagic brain lesions and a cardiac mass. Surgical removal of the cardiac mass and the symptomatic brain lesion confirmed metastatic cardiac myxoma. Post-surgery, she experienced fatigued and neurocognitive impairment and was closely monitored. However, the metastases progressed. She subsequently received whole-brain radiotherapy, resulting in complete response. Seven years later, she remains in remission, although with enduring neurocognitive impairment.

CONCLUSIONS

Whole-brain radiotherapy can provide long-term control of haemorrhagic brain metastases arising from cardiac myxoma. Radiotherapy dose and treatment volume need careful consideration to reduce toxicity.

Incidental Finding of Atrial Myxoma in a Patient Presenting With Transient Ischemic Attack (TIA): A Case Report

Atrial myxomas are benign primary cardiac tumors. They can present with nonspecific symptoms, ranging from constitutional symptoms and embolic phenomena such as transient ischemic attacks (TIAs) or strokes to sudden cardiac death. Early diagnosis may be a challenge due to the nonspecific presentation of atrial myxoma. A high degree of suspicion is needed in patients with TIA having no known cardiovascular risk factors. Although benign, if left untreated, it can lead to serious complications ranging from embolic phenomena and obstructive symptoms to sudden cardiac death. An echocardiogram is of fundamental importance in diagnosing atrial myxoma, and surgical resection is the ultimate treatment of choice. Here, we discuss a case of TIA as the initial presentation of atrial myxoma.

Case report: Multiple brain metastases of atrial myxoma: Clinical experience and literature review

Myxoma is the most common type of benign cardiac tumor in adults, and it has a strong tendency to embolize or metastasize to distant organs. Patients with multiple brain metastases have rarely been seen in clinics; hence, standard treatment protocols for multimyxoma metastasis in the brain have not been established. We present the case of a 47-year-old female who had convulsions in the right hand and repeated seizures. Computed tomography revealed multiple tumor sites in her brain. Craniotomy was conducted to remove the tumor sites. However, recurrent brain tumors and unexpected cerebral infarctions occurred frequently shortly after the treatment because the cardiac myxoma had not been treated due to the patient's personal concerns. The myxoma was resected by gamma knife radiosurgery, and temozolomide was given prior to cardiac surgery. There has been no evidence of tumor recurrence from the 2 years following the surgery until the present. This case highlights the importance of prioritizing cardiac lesions over cerebral lesions; if a cerebral metastasis has been found, it is likely that the cardiac myxoma is already unstable, with high rates of spread and metastasis. Therefore, it is unwise to treat metastasis sites before the cardiac myxoma. Additionally, the case suggests that gamma knife radiosurgery combined with temozolomide is effective as treatment for multiple myxoma metastasis in the brain. Compared with conventional cerebral surgery, gamma knife radiosurgery is safer, causes less bleeding, and requires a shorter time for recovery.

Atypical intracranial aneurysms: spectrum of imaging findings in computed tomography and magnetic resonance imaging

We aim to describe demographics, clinical presentation, and spectrum of CT and MRI features suggestive of atypical intracranial aneurysms. The imaging protocols used for the diagnosis of intracranial aneurysms were thoroughly reviewed, including different CT and MRI protocols. We classified atypical aneurysms according to their location, size, clinical presentation, and specific imaging features. Dissecting aneurysms are one of the causes of stroke in young adults that may show intimal flap and double lumen. Traumatic intracranial aneurysms are a rare but serious complication of head injuries. Mycotic aneurysms are small and multiple at distal branch points with a high risk of rupture. Aneurysms with vasculitis are fusiform with a wide neck at a non-branch point that may be associated with vessel wall enhancement. Atherosclerotic aneurysms are usually large fusiform that affect large arteries. Oncotic aneurysms are relatively rare. They were reported to occur in patients with left atrial myxoma. Our study represented a wide spectrum of atypical intracranial aneurysms with their detailed diagnostic imaging findings on MRI and CT including newly introduced MRI sequences, which greatly influenced early diagnosis and timely management.

Subarachnoid Hemorrhage Following Ischemic Stroke Caused by Atrial Myxoma

Subarachnoid hemorrhage (SAH) is a rare neurological complication of cardiac myxoma and is associated with poor outcomes. Previous reports have shown that myxoma-associated SAH was contributed by rupture of myxomatous intracerebral aneurysm. Here, we present an unusual case of angiographic-negative SAH in a young patient with left atrial myxoma. 

A 28-year-old male was admitted for SAH. He had a history of magnetic resonance imaging (MRI)-confirmed ischemic stroke one year ago. The digital subtraction angiography (DSA) performed on next day revealed no intracerebral aneurysm or vascular malformation. Transthoracic echocardiography (TTE) showed a left atrial mass measuring 5.09 * 3.34 cm, indicating a diagnosis of atrial myxoma, which was confirmed by pathological examination. The cardiac tumor was excised and the patient’s symptoms improved completely. No intracerebral aneurysm was found by brain computed tomographic angiography (CTA) performed on day 24 after onset and one year after discharge. The patient remained asymptomatic during the one-year following-up.

The result suggests that SAH may be more commonly associated with cardiac myxoma than previously expected. And, mechanisms other than rupture of myxomatous intracerebral aneurysm involve in SAH associated with cardiac myxoma. Prolonged length of following-up using novel imaging technique should be applied to identify and monitor the change of source bleeding.

Cerebral embolization associated with parenchymal seeding of the left atrial myxoma: Potential role of interleukin-6 and matrix metalloproteinases

Systemic embolization has been reported in up to 40% of patients with left atrial myxoma, half of them with cerebral involvement. However, development of intracerebral embolization associated with parenchymal seeding of the myxoma emboli is an extremely rare complication, with only 36 histologically diagnosed cases reported in the published literature. We describe a 69-year-old woman who arrived at the emergency service with hemiparesis associated with drug-resistant epilepsy and a medical history of resection of a left atrial myxoma 10 months previously. Cranial computed tomography revealed multiple large lesions of heterogeneous density and cystic components in the occipital lobes and posterior fossa parenchyma. Histopathological analyses after stereotactic biopsy of the occipital lesion revealed infiltrative myxoma cells with benign histological findings and uniform expression of calretinin similar to that of the primary cardiac myxoma. Additional immunohistochemical studies confirmed brain parenchymal seeding of the myxoma cells with strong expression of interleukin-6 (IL-6) and focal expression of matrix metalloproteinases-2 (MMP-2). Here, we discuss the clinicopathological features of intracerebral embolization of left atrial myxomas associated with progressive parenchymal seeding of the tumor emboli and the potential pathogenic role of IL-6 and MMPs.

Autopsy of 54 cases of surgically excised cardiac myxomas. Investigation of their impact on immune response

Introduction

The impact of cardiac myxomas on the immune response is still indefinite, although laboratory tests and histological findings suggest that there is a correlation between myxomas and inflammatory reaction.

Objectives

Our study speculates that cardiac myxomas are associated with inflammatory response and investigates potential elements of inflammation in the histopathological examination and biomarkers from laboratory tests.

Methods

It is a retrospective study and data were collected from a single center between May 2010 to May 2018. Autopsies and laboratory tests of 54 cases were analyzed.

Results

In 20,4% of the autopsies, inflammatory elements were identified. The neutrophil/lymphocyte ratio (NLR) preoperatively is elevated in patients suffering from cardiac myxoma while its value is correlated to the tumor size.

Conclusions

Cardiac myxoma is an entity that affects the immune response of patients. The biomarker NLR could be utilized as a prognostic factor regarding enlarged cardiac myxomas. Future studies still need to be conducted in order to confirm the usefulness of this biomarker on cardiac myxomas.