Multiple cerebral metastases and metastatic aneurysms in patients with left atrial Myxoma: a case report

Two cerebral infarctions caused by thrombus and myxomatous embolus in a patient with cardiac myxoma: A case report

An increasing number of cases of cerebral embolism caused by cardiac myxoma have been reported. However, cerebral infarction caused by different types of emboli obstructing different vascular regions within a short period of time has not been reported. This is the first report to histologically confirm cerebral infarctions independently caused by thrombus and myxomatous embolus in a patient with cardiac myxoma within a period of 23 days. The first cerebral infarction was due to embolization of thrombus to the right middle cerebral artery, whereas the second was due to embolization of tissue from a mucinous tumor to the left middle cerebral artery. Both cerebral infarctions underwent mechanical thrombectomy, but unfortunately, we ultimately failed to save the patient's life. Therefore, further attention should be paid to the surgical resection and treatment of cardiac myxoma.

Multiple craniotomies for the resection of symptomatic multifocal intracranial metastatic cardiac myxoma: A case report

Background

Myxomas, rare benign mesenchymal lesions, are the most common cardiac tumors. Patients may rarely develop hematogenous metastasis to the brain, which can present as new-onset neurological deficits that correlate with multifocal hemorrhagic lesions on imaging. Limited guidelines presently exist for the treatment of such lesions. This report outlines a unique case involving three craniotomies and failed radiation therapy in the treatment of metastatic cardiac myxoma.

Case Description

A 63-year-old woman presented with a right middle cerebral artery embolic stroke secondary to a left atrial myxoma and multifocal hemorrhagic lesions consistent with intracranial metastasis. She had a right frontal craniotomy for tumor resection, followed by stereotactic radiosurgery, though this did not arrest disease progression. She later had a left occipital craniotomy for a symptomatic lesion. More than two years after her initial presentation, she returned with acute-onset symptoms correlating to growth in a left frontal lesion requiring another resection. Following this third craniotomy, imaging has not revealed the progression of metastatic intracranial disease. She is pursuing further treatment through primary cardiac tumor resection.

Conclusion

Although rare, hematogenous seeding with subsequent formation of hemorrhagic metastasis is a possible complication of atrial myxoma. While surgical resection, radiation therapy, and chemotherapy have historically been used, no standard of care currently exists. This case demonstrates repeat tumor resection as effective for managing symptomatic intracranial metastatic myxoma in a patient with poor response to radiation therapy and multiple recurrences, with follow-up showing improvement in neurological symptoms and mass effect and absence of recurrence on imaging.

Visual analysis based on CiteSpace software: a bibliometric study of atrial myxoma

Objective

To use CiteSpace and VOSviewer visual metrology to analyze the research status, frontier hotspots, and trends in research on atrial myxoma.

Methods

The Web of Science core collection database was used to retrieve relevant literature on atrial myxoma from 2001 to 2022. CiteSpace software was used to analyze keywords with a co-occurrence network, co-polymerization class, and burst terms, and a corresponding visual atlas was drawn for analysis.

Results

A total of 893 valid articles were included. The country with the highest number of articles was the United States (n = 186). The organization with the highest number of articles was the Mayo Clinic (n = 15). The author with the highest number of articles was Yuan SM (n = 12). The highest cited author was Reynen K (n = 312). The highest cited journal was Annals of Thoracic Surgery (n = 1,067). The most frequently cited literature was published in the New England Journal of Medicine in 1995, which was cited 233 times. The keywords co-occurrence, copolymerization analysis, and Burst analysis revealed that the main research focuses were surgical methods, case reports, and genetic and molecular level studies on the pathogenesis of myxoma.

Conclusions

This bibliometric analysis revealed that the main research topics and hotspots in atrial myxoma included surgical methods, case reports, genetic and molecular studies.

Cerebral Myxomatous Aneurysms: Case Series and Systematic Review of Literature with Adequate Follow-Up Periods and Aneurysmal Wall Biopsy Results

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.

Cerebral Aneurysms Caused by Atrial Myxoma-A Systematic Review of the Literature

Background: The association between cerebral aneurysms and left atrial myxoma is known but rare. We described its pathogenesis, clinical presentation, diagnostic findings and treatment using a systemic review of the literature. Methods: MEDLINE via PubMed was searched for articles published until August 2022 using the keywords "atrial myxoma", "cardiac myxoma" and "cerebral aneurysm". Results: In this review, 55 patients with multiple myxomas aneurysms were analyzed, and 65% were women. The average age when aneurysms were diagnosed was 42.5 ± 15.81; most patients were less than 60 years old (86%). Aneurysms could be found before the diagnosis, at the same time as cardiac myxoma, or even 25 years after resection of the atrial mass. In our review, the mean time to diagnoses was 4.5 years. Our review estimates that the most common symptoms were vascular incidents (25%) and seizures (14.3%). In 15 cases, variable headaches were reported. Regarding management strategies, 57% cases were managed conservatively as the primary choice. Conclusions: Although cerebral aneurysms caused by atrial myxoma are rare, the long-term consequences can be serious and patients should be monitored.

Cardiac myxomas: A narrative review

Cardiac myxomas are common primary neoplasms of the heart. They are biologically benign but “functionally malignant” because of the potential for embolization. They arise most commonly from the left atrium, but no chambers of the heart are immune. They may be sporadic in the majority but also familial as a part of the Carney complex. Two morphological forms exist: polypoid and papillary. Polypoid myxomas often present with obstructive features, while the papillary forms are more prone to embolization. Histogenesis is still controversial; the current view centres around origin from the primitive pluripotent mesenchymal cells. They may be of giant proportion, be calcified or get infected. Clinical presentation typically involves the triad of intracardiac obstruction, embolic events and constitutional symptoms. Precordial examination findings may simulate those of mitral or tricuspid stenosis. The presence of tumour plop and change of the physical findings with changing position may help differentiation between the two. Echocardiography is the investigation of choice. Echogenic polypoid or papillary mobile mass within the atrial cavity remaining attached to the interatrial septum through a stalk are the tell-tale echocardiographic features. Cardiac magnetic resonance and computed tomographic scanning may have incremental diagnostic value. Histopathological examination reveals abundant loose myxoid stroma with scattered round, polygonal or stellate cells with dense irregular nuclei. Genetic testing may detect mutations in the PRKAR1A gene in the familial form of cardiac myxoma, i.e. the Carney complex. Surgical excision is the mainstay of treatment with low operative mortality, excellent postoperative survival and low recurrence rate. The current trend favours minimal-access surgery with or without robotic assistance. Physicians should have appropriate preparedness to make a timely diagnosis and enthusiastic treatment to avoid potentially fatal complications.

Case Report: Biatrial Myxoma With Pulmonary Embolism and Cerebral Embolism: Clinical Experience and Literature Review

Cardiac myxoma is a common benign primary intracardiac tumor in the general population, and it is generally characterized as a benign tumor, and the morbidity of biatrial myxoma is low. Cases of biatrial myxoma in young patients are extremely rare. Furthermore, severe complications of cardiac myxoma, such as cerebral embolism, can have fatal consequences. Imaging can effectively assist in making a correct diagnosis and a safe and efficient surgical treatment plan. In this case report, we describe a unique case of a young woman who presented with biatrial myxoma accompanied by pulmonary embolism and cerebral embolism. Computed tomography pulmonary angiography (CTPA) detected multiple filling defects in the bilateral cardiac and bilateral inferior pulmonary artery basal branches. Transthoracic echocardiography (TTE) revealed irregular isoechoic masses in the bilateral atrium. Postoperative histopathology confirmed a biatrial myxoma. The patient was discharged on the ninth day after surgery.

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.

Minimally invasive resection of benign cardiac tumors

Primary cardiac tumours for which surgical resection is the main stay of treatment are rare and present both diagnostic and management challenges. The majority of patients are asymptomatic and one third of those who have symptoms present with vague constitutional symptoms which further complicates the process of early diagnosis. The current state-of-the art multi-modality imaging, routine use of intra-operative transoesophageal echocardiogram (TOE) in most cardiac centres and the tremendous advances of endoscopic adjuncts greatly enhances both the diagnosis and management of those group of patients. The surgical burden of median sternotomy and the contemporary trend towards less invasive surgery urged the necessity for adopting minimally invasive surgery in general and cardiac tumours are no exception. Despite the rarity of theses tumours, minimally invasive resection is successful in the hands of experienced minimally invasive surgeons who employ the same minimal access valve surgery platform to access the tumours in various cardiac chambers and valves with no compromise to the oncological clearance and hence achieve the benefits of minimally invasive surgery without compromising long term outcomes.

Hypermetabolic Cerebral Metastases of Cardiac Myxoma on FDG PET/CT

ABSTRACT

A 66-year-old woman with a history of surgical resection of left atrial myxoma 6 months ago presented with multiple brain lesions with MRI. An FDG PET/CT was performed for further evaluation. The images showed that cerebral tumors had variable and increased FDG uptake in general, and no other abnormal FDG-avid lesions were noted. The tumor of right occipital lobe was resected and confirmed as metastatic cardiac myxoma on histology.

Brain manifestations secondary to auricular myxoma

Cardiac myxoma is the most common benign tumor of the heart. In most cases, it is in the left atrium, which can generate neurological embolization; that can manifest as an ischemic event, aneurysm formation and less frequently as brain metastases. This is a case report of a 56-year-old male patient with cerebral embolisms secondary to a left cardiac myxoma. In these patients, the role of neurologic imaging is to detect the firsts complications and avoid secondary complications.

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.