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Choi JH, Park W, Park JC, Ahn JS. Cerebral Myxomatous Aneurysms: Case Series and Systematic Review of Literature with Adequate Follow-Up Periods and Aneurysmal Wall Biopsy Results. World Neurosurg 2023; 172:e107-e119. [PMID: 36566979 DOI: 10.1016/j.wneu.2022.12.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cerebral myxomatous aneurysms (CMA) are intracranial aneurysms caused by cardiac myxoma. The exact mechanism underlying their development has not yet been elucidated. And an optimal treatment method has not yet been established because of rarity of the disease. In addition, most existing reports have had a short follow-up period or lack of follow-up imaging test results. The aim of this study was to provide better insights into the course and treatment options of CMAs. METHODS We describe 4 CMA patients treated in our hospital and literature search was performed using PubMed and Embase databases. Keywords used were as follows: "cerebral myxomatous aneurysm", "myxomatous aneurysm", "cardiac myxoma", and "intracranial aneurysm". Only publications in English and related to this disorder with adequate follow-up periods and aneurysmal wall biopsy results were included. Clinical, radiological, pathological, and treatment characteristics were analyzed. RESULTS A total of 149 CMA cases were managed conservatively that included 9 enlargements, 6 regressions, and 134 stable aneurysms, which were identified for a total of 453.33 aneurysm years (1.91% per aneurysm year, 1.27% per aneurysm year, and 28.76% per aneurysm year, respectively). Poor outcome rate was high in cases with hemorrhage (either parenchymal or subarachnoidal hemorrhage) due to rupture of the CMA (46.67%, 7 out of 15). Thirteen cases had aneurysm biopsy results of which 11 showed tumor invasion on the aneurysm wall. CONCLUSIONS Even though the natural course of unruptured, benign-looking CMAs appears to be favorable, the presence or absence of viable tumor cells in the aneurysm may promote an unfavorable disease course. In the case of large, symptomatic, and enlarging CMAs, surgical, endovascular, or combined treatment should be considered as the mortality and morbidity due to rupture might be high.
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Affiliation(s)
- June Ho Choi
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Wang A, Wang Z, Hu K, Liu J, Cao Q, Zhang Z, Si Z. Delayed multiple intracranial aneurysms caused by left atrial myxoma: a case report and literature review. Transl Pediatr 2022; 11:149-156. [PMID: 35242661 PMCID: PMC8825931 DOI: 10.21037/tp-21-11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
Abstract
Intracranial aneurysm may appear even after the removal of the cardiac myxoma. However, the pathogenesis and treatment of such aneurysm lesions are not clear. The study aimed to explore the clinical and imaging manifestation, hypothetical pathogenesis, and therapy in one case of left atrial myxoma causing multiple intracranial aneurysms. A 14-year-old male displayed a 3-hour history of episodic loss of consciousness and right hemiplegia after a leapfrog-like movement. The myxoma was diagnosed by a combination of clinical examination, leading to the diagnosis of mitral dynamic obstruction with a Grade III mitral diastolic murmur and tumor plop; magnetic resonance imaging, revealing multiple ischemic sites in both semi-oval centers; and transthoracic echocardiography, demonstrating a mitral valve obstruction. The myxoma was removed surgically; however, computed tomography angiography showed multiple intracranial aneurysms in both middle cerebral arteries 18 months after resection of the atrial myxoma. After conservative treatment, the patient had no neurological dysfunction symptoms for 5 years after myxoma resection. His condition is relatively stable. In conclusion, resection of the atrial myxoma may eliminate the early neurological symptoms, but it cannot ensure the nonoccurrence of delayed intracranial aneurysms. The neoplastic process theory was favored for explaining the aneurysm development in this case. According to the specific conditions of the patient, a combination of open surgery, chemotherapy, radiotherapy, and coil embolization is recommended.
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Affiliation(s)
- Aihua Wang
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Jinan, China
| | - Zhaoxia Wang
- Department of Neurology, Juxian People's Hospital, Rizhao, China
| | - Ke Hu
- Department of Emergency Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Emergency Medicine, Jinan, China
| | - Jinzhi Liu
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Jinan, China
| | - Qiwei Cao
- Department of Pathology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pathology, Shandong Lung Cancer Institute, Shandong Institute of Nephrology, Jinan, China
| | - Zixian Zhang
- Department of Neurology, Zaozhuang Municipal Hospital, Zaozhuang, China
| | - Zhihua Si
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Jinan, China
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Zhang R, Tang Z, Qiao Q, Mahmood F, Feng Y. Anesthesia management of atrial myxoma resection with multiple cerebral aneurysms: a case report and review of the literature. BMC Anesthesiol 2020; 20:164. [PMID: 32622360 PMCID: PMC7334857 DOI: 10.1186/s12871-020-01055-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 05/25/2020] [Indexed: 11/23/2022] Open
Abstract
Background Embolic stroke is a common complication of atrial myxoma, whereas multiple cerebral aneurysms associated with atrial myxoma is rare. The pathogenesis of the cerebral vascular disease related to an atrial myxoma is still not well known, and there are no guidelines to guide treatment and anesthesia management in such patients. Case presentation In this report, we present a 38-year-old woman with occasional dizziness and headache diagnosed as multiple cerebral fusiform aneurysms, in whom transthoracic echocardiography revealed a mass attached to the interatrial septum in the left atrium. Myxoma resection was performed in fast track cardiac surgery pathway without neurological complications, and no intervention was carried out on the cerebral aneurysms. She was discharged home 6 days after the procedure for followed-up. Furthermore, we reviewed and analyzed the literature in the PubMed and Google Scholar databases in order to conclude the optimal treatment in such cases. Conclusions Atrial myxoma-related cerebral aneurysms are always multiple and in a fusiform shape in most occasions. Early resection of myxoma and conservative therapy of aneurysm is an optimal treatment. TEE and PbtO2 monitoring play an essential role in anesthesia management. Fast track cardiac anesthesia is safe and effective to early evaluate neurological function. Long term follow-up for “myxomatous aneurysms” is recommended. And outcome of most patients is excellent.
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Affiliation(s)
- Ran Zhang
- Department of Anesthesiology, Peking University People's Hospital, No. 11 Xi Zhi Men Nan Da Jie, Xicheng District, Beijing, China
| | - Zhiyu Tang
- Department of Anesthesiology, Peking University People's Hospital, No. 11 Xi Zhi Men Nan Da Jie, Xicheng District, Beijing, China
| | - Qing Qiao
- Department of Anesthesiology, Peking University People's Hospital, No. 11 Xi Zhi Men Nan Da Jie, Xicheng District, Beijing, China
| | - Feroze Mahmood
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, USA
| | - Yi Feng
- Department of Anesthesiology, Peking University People's Hospital, No. 11 Xi Zhi Men Nan Da Jie, Xicheng District, Beijing, China.
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Gai S, Lv N, Zhang Q, Zuo Q, Liu J, Huang Q. Multiple Intracranial Aneurysms Caused by Myxoma: Case Report and Literature Review. World Neurosurg 2020; 133:e376-e384. [DOI: 10.1016/j.wneu.2019.09.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 10/26/2022]
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Santillan A, Knopman J, Patsalides A, Pierre Gobin Y. Delayed intracranial aneurysm formation after cardiac myxoma resection: Report of two cases and review of the literature. Interv Neuroradiol 2018; 25:177-181. [PMID: 30394840 DOI: 10.1177/1591019918808026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Myxomas are slowly growing benign neoplasms and represent the most common tumor of the heart. Embolism from cardiac myxoma occurs in 30-45% of patients and in at least half of the cases cerebral arteries are affected leading mainly to embolic ischemic strokes and rarely to delayed intracranial aneurysm formation. We present two cases with delayed intracranial aneurysmal formation 14 years and 18 years after cardiac myxoma resection. To the best of our knowledge these two cases represent the longest time interval between aneurysm detection after complete cardiac myxoma resection with no recurrence confirmed by transesophageal echocardiogram. Our study also provides the longest clinical and radiological follow-up on this type of lesion.
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Affiliation(s)
- Alejandro Santillan
- Division of Interventional Neuroradiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, USA
| | - Jared Knopman
- Division of Interventional Neuroradiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, USA
| | - Athos Patsalides
- Division of Interventional Neuroradiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, USA
| | - Y Pierre Gobin
- Division of Interventional Neuroradiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, USA
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Lazarow F, Aktan S, Lanier K, Agola J. Coil embolization of an enlarging fusiform myxomatous cerebral aneurysm. Radiol Case Rep 2018; 13:490-494. [PMID: 29904496 PMCID: PMC5999827 DOI: 10.1016/j.radcr.2017.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 11/17/2017] [Accepted: 11/30/2017] [Indexed: 11/15/2022] Open
Abstract
Myxomatous cerebral aneurysms are rare sequelae of cardiac atrial myxoma. These aneurysms are generally fusiform, multiple, and distal. Pathogenesis and evolution of these aneurysms is still debated. There are currently no guidelines on the management of aneurysms secondary to atrial myxoma. We present a case of a 52-year-old man with multiple fusiform aneurysms 3 years after resection of a left atrial myxoma. One of these aneurysms was followed with cerebral angiography and showed substantial interval enlargement. This aneurysm was subsequently embolized. All aneurysms were stable 6 months post-embolization.
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Affiliation(s)
- Frances Lazarow
- Department of Radiology, Eastern Virginia Medical School, P.O. Box 1980 Norfolk, VA
| | - Serra Aktan
- School of Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Karah Lanier
- Department of Radiology, Eastern Virginia Medical School, P.O. Box 1980 Norfolk, VA
| | - John Agola
- Department of Radiology, Eastern Virginia Medical School, P.O. Box 1980 Norfolk, VA
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Flores PL, Haglund F, Bhogal P, Yeo Leong Litt L, Södermann M. The dynamic natural history of cerebral aneurysms from cardiac myxomas: A review of the natural history of myxomatous aneurysms. Interv Neuroradiol 2018; 24:277-283. [PMID: 29383976 DOI: 10.1177/1591019917754070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
We describe two contrasting patients with multiple cerebral aneurysms and a previous history of resected cardiac myxomas with no cardiac recurrence on follow-up echocardiography. Both patients presented with stroke- like symptoms; one with a left visual defect and the other with right hemiplegia. Magnetic resonance imaging of the brain of both patients showed the presence of multiple cerebral aneurysms that was later confirmed on conventional angiography. Both patients' aneurysms were managed conservatively. Serial angiograms were performed during their follow-up, which spanned several years. One patient's aneurysms remained static while the evolution of the other patient's aneurysms displayed a dynamic quality with some increasing in size while others diminished. This is the first description in which some aneurysms progressed while others regressed simultaneously in the same patient. Aneurysms in patients with a history of cardiac myxoma can be active years after primary tumor resection and it is difficult to predict how they will develop. We reviewed the literature of all patients with multiple myxomatous aneurysms who were treated conservatively to better understand the natural history of this rare disease. Long-term follow-up of these patients may be necessary.
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Affiliation(s)
- Paloma Largo Flores
- 1 Unit of Interventional Neuroradiology, Radiodiagnostic Service, University Hospital La Princesa, Madrid, Spain
| | - Felix Haglund
- 2 Department of Oncology-Pathology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | | | - Leonard Yeo Leong Litt
- 4 Division of Neurology, Department of Medicine, National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,5 Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Södermann
- 5 Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
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Rokadia HK, Heresi GA, Tan CD, Raymond DP, Budd GT, Farver C. A 33-year-old man with multiple bilateral pulmonary pseudoaneurysms. Chest 2016; 148:e112-e117. [PMID: 26437818 DOI: 10.1378/chest.15-0624] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
A 33-year-old man, never smoker, presented with acute-onset dyspnea secondary to bilateral pulmonary emboli. Echocardiography at the time revealed a right atrial myxoma, for which he underwent resection, followed by anticipated lifelong therapeutic anticoagulation therapy.
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Affiliation(s)
| | | | - Carmela D Tan
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland OH
| | - Daniel P Raymond
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland OH
| | | | - Carol Farver
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland OH
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Multiple Cerebral Myxomatous Aneurysms: What Is the Optimal Treatment? J Stroke Cerebrovasc Dis 2015; 24:232-8. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.08.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 08/17/2014] [Accepted: 08/22/2014] [Indexed: 11/30/2022] Open
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Neoplastic cerebral aneurysm from metastatic tumor: a systematic review of clinical and treatment characteristics. Clin Neurol Neurosurg 2014; 128:107-11. [PMID: 25484302 DOI: 10.1016/j.clineuro.2014.11.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Revised: 10/30/2014] [Accepted: 11/16/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Neoplastic cerebral aneurysm (NCA) is a very rare event. The authors aimed to characterize the clinical and treatment details of this poorly defined entity. MATERIALS AND METHODS A computerized systematic literature search was performed in PubMed, Medline, Web of Science, Cochrane Library, Embase, Google Scholar, Science Direct and Scopus. Keywords used were as follows: "aneurysm"; "myxoma"; "choriocarcinoma"; "oncotic aneurysm"; "neoplastic aneurysm". Only reports with cerebral aneurysm resulting from metastatic tumor and contained adequate clinical information pertinent to the analysis were included. Clinical and treatment characteristics were analyzed. RESULTS Ninety-two studies reporting 96 cases of neoplastic cerebral aneurysm were identified. NCA from cardiac myxoma accounted for 60.4%, while NCA from choriocarcinoma and other tumors accounted for 26.1% and 13.5%, respectively. The rates of intracranial hemorrhages were 19.6% in NCA from myxoma, 100% in NCA from choriocarcinoma, and 84.6% in NCA from other tumors. 75.9% of NCA from myxoma were managed conservatively, 92% of NCA from choriocarcinoma were treated by surgery and/or chemotherapy, and 69.2% of NCA from other tumors were treated by surgery with or without chemotherapy. The mortality rates were 11.4% in NCA from myxoma, 60.9% in NCA from choriocarcinoma, and 92.3% in NCA from other tumors. According to a multiple logistic regression model, "pathology (P = 0.002)" is significantly correlated with outcome. CONCLUSIONS Neoplastic cerebral aneurysms are usually complicated with cardiac myxoma, choriocarcinoma and lung carcinoma. NCA from cardiac myxoma were probably multiple and rarely associated with intracranial hemorrhage, while the majority of NCA from choriocarcinoma and other tumors were single and presented with intracranial hemorrhage. The prognosis is quite good in NCA from cardiac myxoma, while NCA from malignant tumors were associated with poor outcome.
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