Cardiac myxoma: a diagnostic challenge for the neurologist

Prognostic prediction of troponins in cardiac myxoma: case study with literature review

Objective

It was supposed that troponins in cardiac myxoma patients might be in a same fashion as in the conditions without myocardial injury. In order to verify this hypothesis, troponins in cardiac myxoma patients were discussed by presenting a comprehensive retrieval of the literature with incorporating the information of a recent patient.

Methods

Postoperative detections of troponin I, creatine kinase isoenzyme MB (CK-MB) and N-terminal pro-B-type natriuretic peptide revealed elevated troponin I and CK-MB and normal N-terminal pro-B-type natriuretic peptide. Postoperative troponin I and CK-MB shared a same trend, reaching a peak value at postoperative hour 2, gradually decreased on postoperative day 1, and reached a plateau on postoperative days 7 and 13. A significant correlation could be noted between the postoperative values of the two indicators (Y=0.0714X + 0.6425, r²=0.9111, r=0.9545, P=0.0116). No significant linear correlation between troponin I and N-terminal pro-B-type natriuretic peptide were found. Literature review of troponins in cardiac myxoma patients revealed the uncomplicated patients had a normal or only slightly elevated troponin before open heart surgery. However, the complicated patients (with cerebral or cardiac events) showed a normal preoperative troponin in 3 (23.1%) and an elevated troponin in 10 (76.9%) patients (χ²=7.54, P=0.0169, Fisher's exact test). The overall quantitative result of troponin I was 2.45±2.53 µg/L, and that of troponin T was 3.10±4.29 mg/L, respectively.

Conclusion

Troponins are not necessarily elevated in patients with a cardiac myxoma without coronary syndrome. By contrast, patients with a cardiac myxoma with an elevated troponin may herald the presence of an associated coronary event. An old cerebral infarct does not necessarily cause an elevation of troponin or B-type natriuretic peptide, or new neurological events, but might lead to a delayed awakening.

Neurologic complications of cardiac tumors

Cardiac tumors are an uncommon cause for neurologic disease, but if undiagnosed can be associated with devastating neurologic consequences. Primary cardiac tumors, both benign and neoplastic, and metastatic tumors occur. Primary cardiac tumors are more likely to be associated with neurologic embolic complications. Metastatic cardiac tumors are more likely to be associated with valvular distraction, arrhythmia, diminished cardiac output and indirect neurological dysfunction. Primary and metastatic cardiac tumors may result in cerebral metastatic disease. Atrial myxoma, a benign primary cardiac tumor, is the most common cardiac tumor associated with neurologic disease, and most commonly causes cerebral embolization and stroke. The use of thrombolytic therapy for these strokes is controversial. Additionally, delayed manifestations, including aneurysm formation and intracranial hemorrhage, are possible. Aneurysm formation has been described as occurring after removal of the primary tumor. The availability of noninvasive cardiac imaging has significantly helped decrease the neurologic morbidity of cardiac tumors and has led to frequent successful intervention.

Cerebral embolism from atrial myxoma in pediatric patients

We describe 2 children with cerebrovascular events caused by emboli from left atrial myxomas and review 7 other pediatric cases from the literature. Transient cutaneous eruptions involving the extremities preceded the cerebrovascular events and were most likely attributable to fragmentation of the atrial tumor with peripheral embolization. Our first case demonstrates the more common presentation with acute hemiplegia caused by cerebral infarction and the second case a transient ischemic attack manifested by more subtle features as a result of involvement of the vertebrobasilar circulation. Neither child had a history or other signs of cardiac disease. Atrial myxoma should be considered in the differential diagnosis when children present with neurologic symptoms or with signs of embolization, because surgical removal of the tumor is critical and may be curative.

Stroke and Myxoma

Cardiac myxoma was detected by transthoracic echocardiography in 8 patients (aged 11 to 64 years) who were admitted between 1991 and 1999 with stroke or transient ischemic attacks, representing 80% of the total myxoma cases treated in this period. All patients underwent surgery and the myxomas were successfully removed. There were no recurrences during a mean follow-up of 3.1 years. In the presence of unexplained transient ischemic attack, cerebral infarction, or syncope, this relatively rare cardiac lesion should be suspected and investigated by transthoracic echocardiography.

[Cerebral infarction, pseudolupic syndrome and myxoma of the left atrium]

Left atrial myxomas are a rare stroke etiology (0.4%). They frequently present general symptoms such as fever, weight loss and an inflammatory syndrome, but the pseudolupic syndrome with cutaneous features and vasomotor symptoms is rarely described. We report the case of a 38-year old man who presented in March 1995 a stroke caused by a left atrial myxoma. There was also pseudolupic clinical and biological manifestations which disappeared after ablation of the myxoma. Cerebral angiography showed a small carotid aspect which evoked carotid dissection or carotid siphon occlusion. The authors discuss neurologic and pseudolupic manifestations of left atrial myxomas, and their physiopathologic mechanism.

Cutaneous eruption in a patient with cardiac myxoma

Atrial myxoma was diagnosed in a young woman who had cutaneous and constitutional manifestations clinically suggestive of cutaneous vasculitis without cardiac signs or symptoms. Scrupulous physical and laboratory examinations excluded additional medical disorders. The patient was totally cured by surgical removal of the tumor. Various aspects of the association of cardiac myxoma with dermatological findings are discussed, emphasizing the importance of echocardiography in the diagnostic workup of various skin abnormalities, including unexplained vasculitis, even in the absence of cardiac findings.

Syncope

Syncope is a common admitting diagnosis to intensive care units; however, in half the cases, the etiology goes undiagnosed. The prognosis is adversely affected in patients with a cardiogenic etiology. We discuss the clinical presentation and pathophysiology of cardiovascular causes of syncope (including arrhythmia and conduction disturbances, myocardial disorders, and valvular disorders), vascular causes (obstruction and decreased venous return), peripheral vascular causes (arterial and venous), and noncardiovascular causes (neurological and hematological). A thorough history and physical examination are the best diagnostic tools. In addition, electrocardiograms and 24-hour telemetry monitoring are also useful. Other diagnostic tests should be ordered judiciously, depending on the findings of the initial evaluation. Medical or surgical treatment is directed at the underlying cause.

Neurological long-term follow-up in left atrial myxoma: are late complications frequent or rare?

Neurological manifestations were analysed in 13 patients with left atrial myxoma confirmed by histological study. In this group, 6 patients had neurological complaints at initial presentation, 5 had cardiac symptoms, and 4 patients presented with signs of systemic disease. CT was performed in 10 and MRI in 7 patients. There were signs of ischaemic or haemorrhagic infarction (6 of 12) and one lesion suggestive of myxoma metastasis; other findings mainly comprised non-specific white matter lesions revealed by MRI. Neurological follow-up 0.5-8 years after tumour resection revealed no delayed neurological complications, follow-up CT and MRI findings were not suggestive of lesions acquired after operation. It is suggested that this rare condition of cardiac myxoma should be suspected in young patients with CNS symptoms or signs lacking cerebrovascular or cardiovascular risk factors and should be included in the differential diagnosis of vasculitis. With timely diagnosis and resection of the cardiac tumour the long-term prognosis can be considered improved.

Intracardiac rhabdomyosarcoma: transesophageal echocardiographic findings and diagnosis

Transesophageal echocardiography (TEE) was performed on a 41-year-old woman who presented with a cerebrovascular accident. TEE confirmed the presence of a morphologically bizarre biatrial tumor with precarious, vigorous motion throughout the cardiac cycle. Surgical intervention was decided on, and the patient underwent cardiac surgery for tumor excision 16 hours after TEE. Intraoperative frozen section diagnosis was spindle cell sarcoma, and subsequent immunohistochemical analysis showed the tumor to be a rhabdomyosarcoma. The data are presented here, and the role of TEE to establish a preoperative diagnosis of intracardiac tumor is discussed.

Right atrial myxoma with a nonembolic intestinal manifestation

A 5-year-old male with right atrial myxoma without interatrial communication who presented with abdominal pain, vomiting, fever, and guaiac positive stool is reported. He was later found to have ischemia of a jejunal segment necessitating segmental resection. Although his symptoms persisted postoperatively, surgical removal of a right atrial myxoma was followed by complete resolution of his intestinal symptoms. We demonstrated that the mesenteric vasculitis was of nonembolic origin, and we speculate autoimmune arteritis as a possible mechanism.

Neurologic manifestations of atrial myxoma. A 12-year experience and review

We present the results of a 12-year retrospective analysis of 11 patients, eight women and three men, aged 16-76 years, with pathologically documented atrial myxomas. Nine of the 11 patients were found to have a left atrial myxoma; right atrial myxomas were identified in two. Five of the 11 patients (45%) had abnormalities on neurologic examination, and five of five had computed tomographic evidence of nonhemorrhagic cerebral infarction. Neurologic symptoms were the initial presentation in four patients. Six patients reported a history of cardiac disease; eight of the 11 had abnormalities on cardiac auscultation. Echocardiography in 10 patients was diagnostic in all but one. Gated magnetic resonance imaging of the heart in two patients demonstrated myxoma position and movement. Follow-up examinations (varying from 1 month to 7 years after tumor resection) in nine of 11 patients demonstrated no recurrent neurologic symptoms. Cerebral infarction is a common complication of atrial myxomas and may be the presenting feature. Recurrent cerebral emboli before surgery is not uncommon. Cardiac auscultation may be normal, and electrocardiographic changes are often nonspecific. Delayed neurologic events following surgery are rare.

Improved surgical approach to cardiac tumors with intraoperative two-dimensional echocardiography

Intraoperative two-dimensional echocardiography allows visualization of cardiac anatomy and function not possible by other techniques. Although preoperative evaluation by noninvasive methods is usually adequate for diagnosis of cardiac tumors, two-dimensional echocardiography can be beneficial intraoperatively. Intraoperative echocardiography provides an accurate evaluation of cardiac anatomy, extent of tumor invasion, valvular function and the possible presence of intracardiac communications. Importantly, following tumor resection and a complex operative reconstructive procedure, the echocardiogram can confirm complete intracardiac tumor excision, evaluate post-repair ventricular function, and exclude an intracardiac communication or valvular insufficiency.

Cardiac tumours simulating collagen vascular disease

Cardiac tumours can mimic collagen vascular disease and they are often accompanied by profound systemic upset. Both benign and malignant tumours may present in this way. Three cases of cardiac tumour, two malignant and one benign, are reported with just such a presentation. A review of fifteen similar case reports showed that a spectrum of different collagen vascular diseases was diagnosed and treated before the true diagnosis emerged. In half of these cases the cardiac tumour was only diagnosed at necropsy. The diagnosis of collagen vascular disease should not be made in the absence of corroborative laboratory data. In cases of malignant cardiac tumour, and less commonly with atrial myxoma, M mode and cross sectional echocardiography may not exclude the diagnosis. There may be a good response to steroid treatment in cases of suspected but not confirmed collagen vascular disease in which the true diagnosis is cardiac tumour.

Cerebral ischemic accidents of cardiac origin

The cardiac causes of cerebral ischemia, particularly the origins and etiology of embolism, are described in some detail.

Delay in diagnosis of right atrial myxoma

Clinical, echocardiographic, and nuclear angiographic findings in a 51-year-old woman who presented with a history of dyspnea are discussed. Initial echocardiography revealed no abnormality. However, a subsequent radionuclide angiogram revealed a filling defect on the right side of the heart. This represented a right atrial myxoma. Radionuclide angiography can provide a useful noninvasive tool in the diagnosis of intracardiac tumors when echocardiography has not been helpful.

Primary tumors of the heart: a review with emphasis on diagnosis and potential treatment modalities

Primary cardiac tumors, while uncommon, are not rare neoplasms. They occur in individuals of all ages. A variety of benign and malignant tumors has been described. Presenting signs and symptoms mimic numerous systemic and cardiac disease states. Echocardiography, catheterization, and nuclear magnetic resonance techniques are diagnostic tools available to the physician. Early diagnosis and surgical intervention are curative measures for many benign cardiac tumors. Malignant variants are uniformly unresponsive to treatment.

Case report: organic brain syndrome due to multiple tumour emboli

A case of rapid neurological deterioration in a 60-year-old man with oesophageal carcinoma is reported. He suffered two episodes of global cerebral dysfunction following traumatic endoscopic manipulation. Autopsy findings showed multiple tumour emboli which occluded medium and small-sized vessels in cortical and subcortical areas, resulting in multiple microinfarcts.

The role of echocardiography in the investigation of focal cerebral ischaemia

One-hundred and ten patients referred for echocardiography to exclude a cardiac source of cerebral emboli were prospectively studied. Four patients with known cardiac abnormalities, for which they were receiving inadequate anticoagulation, were excluded from the study, and 18 patients were subsequently found to have a non-embolic cause for their cerebral pathology. Twenty-eight patients with a normal clinical examination, chest X-ray and electrocardiogram, and 27 patients with hypertension alone had echocardiograms which did not reveal a cardiac source of embolus. Of the remaining group of 33 patients, six were found to have a probable cardiac source of embolus and nine had abnormalities which may be associated with cerebral emboli. Echocardiography may not be indicated in patients with a normal clinical examination, chest X-ray and electrocardiogram, and in patients with hypertension alone. However, if these patients are excluded echocardiography gives a high yield of positive findings which may be of practical importance in the management of the patient.

Left atrial myxoma presenting with synchronous carotid and femoral embolism

Synchronous embolism of the right femoral and the left internal carotid arteries, occurring in a 39-year-old teacher upon physical effort, was found to be due to a left atrial myxoma. Clinical findings, electrocardiogram and chest radiographs had suggested myocarditis. The patient died of cerebral infarction. In cases of suspected myocarditis, left atrial myxoma has to be considered in the differential diagnosis. Histological examination is recommended of any material obtained by embolectomy.

Two dimensional echocardiographic detection of intraatrial masses

With two dimensional echocardiography, a left atrial mass was detected in 19 patients. Of these, 10 patients with rheumatic mitral stenosis had a left atrial thrombus. The distinctive two dimensional echocardiographic features of left atrial thrombus included a mass of irregular nonmobile laminated echos within an enlarged atrial cavity, usually with a broad base of attachment to the posterior left atrial wall. Seven patients had a left atrial myxoma. Usually, the myxoma appeared as a mottled ovoid, sharply demarcated mobile mass attached to the interatrial septum. One patient had a right atrial angiosarcoma that appeared as a nonmobile mass extending from the inferior vena caval-right atrial junction into the right atrial cavity. One patient had a left atrial leiomyosarcoma producing a highly mobile mass attached to the lateral wall of the left atrium. M mode echocardiography detected six of the seven myxomas, one thrombus and neither of the other tumors. Thus, two dimensional echocardiography appears to be the technique of choice in the detection, localization and differentiation of intraatrial masses.

[Clinical findings on heart myxoma (authors' translation)]

Clinical findings, diagnosis, and pathology of heart myxoma are discussed on the basis of personal experience with nine patients. There was a striking variety of signs and symptoms caused by tumor embolization, hemodynamic obstruction, and autoimmunologic reactions. Echocardiography is the method of choice, although angiography may still be necessary in atypical or negative echocardiographic findings. The tumor should be removed as soon as possible after diagnosis. There is danger of tumor embolization in the course of the operation. Long-term results are good, if resection of the tumors is performed before catastrophic complications occur. Morphologically, myxomas are genuine tumors characterized by myxomatous stromata and cells.

Left atrial myxoma presenting as a systemic vasculitis

Left atrial myxoma has often stimulated systemic vasculitis or a connective tissue disease, but the diagnosis is usually suggested by cardiac symptoms or signs. The present case report is both unusual and instructive in that the patient presented with a painless left foot drop followed by digital vasculitis. Laboratory findings included depressed total hemolytic complement and elevated anti-double-stranded DNA. Despite frequent and careful observation, a heart murmur was not appreciated. Because of the unusual features and the patient's frequent military travels, the diagnosis of left atrial myxoma was not established for 8 months. This case history stresses the importance of considering the possibility of atrial myxoma in patients with heart murmurs whose symptoms, physical findings, and laboratory studies could be compatible with a systemic vasculitis.

Embolism to the central nervous system from cardiac myxoma. Report of two cases

Two cases of left atrial myxoma are reviewed, both presenting as embolic phenomena. Neither patient gave a history compatible with pre-existent cardiac dysfunction. Sudden collapse and subsequent right hemiplegia resulted in one patient when an embolus lodged in the left middle cerebral artery. The second patient presented with headache and transient visual obscuration in the left eye. She showed evidence of embolism to the central retinal artery, and particulate matter could be seen within the retinal arterioles. Attention is drown to the fact that echocardiography now constitutes a simple, noninvasive, and highly reliable method of making this diagnosis. The propensity for embolic tumor fragments to grow and invade cerebral arterial walls is discussed along with its possible neurosurgical significance.