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