The dynamic natural history of cerebral aneurysms from cardiac myxomas: A review of the natural history of myxomatous aneurysms

Abstract

We describe two contrasting patients with multiple cerebral aneurysms and a previous history of resected cardiac myxomas with no cardiac recurrence on follow-up echocardiography. Both patients presented with stroke- like symptoms; one with a left visual defect and the other with right hemiplegia. Magnetic resonance imaging of the brain of both patients showed the presence of multiple cerebral aneurysms that was later confirmed on conventional angiography. Both patients' aneurysms were managed conservatively. Serial angiograms were performed during their follow-up, which spanned several years. One patient's aneurysms remained static while the evolution of the other patient's aneurysms displayed a dynamic quality with some increasing in size while others diminished. This is the first description in which some aneurysms progressed while others regressed simultaneously in the same patient. Aneurysms in patients with a history of cardiac myxoma can be active years after primary tumor resection and it is difficult to predict how they will develop. We reviewed the literature of all patients with multiple myxomatous aneurysms who were treated conservatively to better understand the natural history of this rare disease. Long-term follow-up of these patients may be necessary.

Keywords: Aneurysm; myxoma; natural history; progression.

Figure 1.

(a) and (b) Left vertebral artery digital subtraction angiography anteroposterior and lateral views showing a fusiform aneurysm in the left posteroinferior cerebellar artery. (c) Right internal carotid artery digital subtraction angiography lateral view showing two aneurysms in the M2 segment of the right middle cerebral artery.

Figure 2.

(a) Histology of the resected tumor showing loosely packed cords of stellate and plump cells with eosinophilic cytoplasm containing vacuoles within a bland myxoid stroma. The surface of the tumor was generally villous. (b) Similar histology showing loosely arranged cords of stellate and plump cells with eosinophilic cytoplasm and vacuoles, with a varyingly smooth or villous surface. The central part of the lesion was fibrotic containing myxoma cells and hemosiderin-containing macrophages indicating an earlier bleeding.

Figure 3.

Lateral views of serial digital subtraction angiographies in (a) 2011, (b) 2013, (c) 2014 and (d) 2016, showing enlargement and regression in different aneurysms simultaneously in the left internal carotid artery territory.

Figure 4.

Digital subtraction lateral views after contrast injection of the left external carotid artery showing transdiploic blood supply to the left parietal lobe that developed between 2011 and 2014.