Discussion
Atrial myxoma usually present with dyspnea, palpitations or fatigue and
are more common in women. Atrial myxoma presenting as stroke is a rare
condition. However, it can potentially lead to varied neurological
complications in 20-35 % of the patients.5 This case
report emphasizes on the rare neurological manifestation of left atrial
myxoma first presenting as an embolic stroke in a middle aged male
patient, with no other cardiovascular symptoms. Usually, it obstructs
the mitral inflow and causes fatigue and dyspnea due to reduced forward
flow and elevated pulmonary venous pressure respectively. There may be
enlargement of the left atrium, atrial arrhythmias and palpitations.
Being a highly mobile and friable structure, its fragments may get
dislodged and embolise to the cerebral circulation causing stroke.
Bilateral multiple infarcts as found in our case usually point towards
cardio embolic etiology. Although cardio-embolic stroke is most commonly
caused by left atrial thrombus due to valvular or non-valvular atrial
fibrillation. While, globally non-valvular atrial fibrillation is the
most common cause of cardio-embolic stroke, in developing countries,
rheumatic heart diseases (RHD) with severe mitral stenosis still remains
a very common cause. Atrial myxoma are quite a rare cause for stroke,
especially as the presenting symptom, like in our
case.7
This case report serves as a reminder, that can contribute to raise
awareness and emphasize on the importance of quickly ruling out
cardioembolic causes of ischemic stroke that are unrelated to
hypercoagulability.5 It reinforces the need for need
for a two dimensional echocardiography as a part of basic cardiac workup
in patients presenting with stroke. In our patient, two-dimensional
echocardiography was performed which showed a 39×20 mm large homogeneous
mobile left atrial mass attached to the interatrial septum. Multiple
imaging characteristics—large size, attachment to the interatrial
septum, mobility, and prolapse across atrio-ventricular valve—made
myxoma the most likely diagnosis.
The diagnosis of an atrial myxoma warrants its resection and it should
be done immediately due to anticipated risk of embolization, arrhythmias
and sudden cardiac mortality occurring in about 10 % of patients
waiting for surgery.8 When it is resected completely
with no residual tumour, the chances of recurrence is rare with good
long term outcomes.9 Our patient had already suffered
embolism and in order to prevent further episodes he was immediately
taken up for surgical excision of the mass. Apart from imaging,
histopathological findings are essential to confirm the diagnosis and
provide prognostic information.9