Major Stroke as the First Clinical Manifestation of Cardiac Myxoma: Management with Stentriever-Assisted Tumor Thrombectomy

Cardiac myxoma is the most common primary cardiac tumor in adults, accounting for up to 83% of all primary cardiac tumors. Myxomas are most common in the third to sixth decades of life and have a 2:1 female predominance. Most occur in the left atrium. Obstructive symptoms such as dizziness, palpitations, dyspnea, heart failure, syncope, and constitutional symptoms such as myalgia, arthralgia, weight loss, fatigue, fever, Raynaud’s phenomenon, and clubbing of the fingers are the most common presenting symptoms of the intracavitary mass. However, neurological complications, especially embolic stroke, may be the first manifestation of atrial myxoma. In patients with myxoma and neurological symptoms, embolic ischemic stroke is the most common neurological manifestation. In young adults with embolic ischemic stroke, prompt cardiologic evaluation and echocardiographic diagnosis are of paramount importance to prevent recurrent complications. A 53-year-old woman had a history of arterial hypertension, gout, obesity, and a 6-month history of generalized weakness (asthenia), dizziness, and palpitations. She had experienced an isolated episode of syncope the previous month while working as a cook. Blood tests had revealed mild anemia and dyslipidemia. A cardiologic evaluation 4 years earlier, including an echocardiogram and stress test, was reported as unremarkable. She was brought to the emergency department 100 min after she was last seen well. On arrival, she had right gaze deviation, anarthria with preserved understanding, and left hemiparesis. Her National Institutes of Health Stroke Scale (NIHSS) score was 16. Admission CT showed extensive ischemic changes in the frontoparietal cortical regions and basal ganglia of the right hemisphere (Alberta Stroke Program Early CT Score [ASPECTS] 3). CT perfusion (CTP) images showed a 108 ml region with total cerebral blood flow reduced to less than 30% of expected levels, with low perfusion volume predominantly in the frontoparietal regions. The region with a time-to-maximum prolongation >6 s had a total volume of 154 ml, for a mismatch volume of 46 ml and a mismatch ratio of 1.4. CT angiography (CTA) demonstrated occlusion of the right internal carotid artery (ICA) terminus. Despite the extensive infarct core on admission, intravenous tissue plasminogen activator (IV-tPA) was administered, and the patient showed mild improvement in left arm weakness. She underwent stentriever-assisted mechanical thrombectomy, which achieved rapid complete reperfusion and distal filling of all branches (modified Treatment in Cerebral Ischemia [mTICI] score of 3), resulting in clinical improvement. Electrocardiographic monitoring revealed sinus rhythm, but a routine echocardiogram showed a left atrial tumor mass compatible with myxoma. The patient underwent surgical excision of the tumor and was treated with oral anticoagulation. During follow-up, she made a remarkable neurological recovery despite a large right hemispheric infarction. Major ischemic stroke due to cardiac myxoma is rarely encountered in medical practice. This chapter discusses the diagnosis and management of stroke and myxoma. In the case presented here, the stroke was preceded by several months of dizziness and syncope. The major stroke was treated as usual, with intravenous thrombolysis and mechanical thrombectomy. It is important to recognize the limitations of thrombolysis and the efficacy and safety of mechanical reperfusion. Routine cardiologic evaluation identified the myxoma, allowing surgical excision of the tumor and preventing further complications.