Assessment of embolic cardiomyopathy from atrial myxoma on magnetic resonance imaging: A case report

Abstract

Atrial myxoma is the most common benign cardiac tumor, which can present with diverse symptoms. Systemic embolism is a frequent complication, affecting up to one-third of cases and frequently involving cerebral arteries. However, cardiac myxoma-induced myocardial infarction (MI) is rare. We report a case of a 56-year-old man presenting with predominant neurological symptoms and an unexplained elevation of hs-Trop T without clinical signs of acute MI. Computerized tomography of the head showed no acute lesions, but subsequent magnetic resonance imaging (MRI) revealed multiple small ischemic lesions and old microhemorrhage foci. A comprehensive cardiovascular investigation was performed. Ultrasonography revealed a left atrial mass. Cardiac MRI confirmed the mass was an atrial myxoma, and showed many old infarctions and scarring lesions in the cardiac muscle. The patient underwent tumor resection, but residual motor-neurological deficits were observed. This case emphasizes the importance of cardiac MRI in the diagnosis of multiple focal infarctions attributed to coronary embolism.

Keywords: Atria myxoma; CT; Cardioembolic cerebral infarction; Embolic myocardial infarction; MR.

Fig. 1

Initial magnetic resonance imaging of the brain: T2W, DWI, and ADC images (A–C) showing bilateral distribution of multiple small acute ischemic lesions and multilevel infarcts. The DWI images (B, D, E) showing restricted diffusion within the cerebellar hemispheres, as well as the temporal, parietal, and occipital cortex, primarily affecting the posterior circulation. The SWI images (F) reveal multiple old cerebral microbleeds, especially within the deep gray matter and posterior fossa."

Fig. 2

Transthoracic echocardiography during hospitalization showing a large, mobile, lobulated, heterogeneous echoic mass, attaching to the interatrial septal and prolapsing through the mitral valve in diastole, along with the reduction of wall motion in the apical region.

Fig. 3

Contrast-enhanced cardiac MRI showing a mass with an intermediate signal on T1-weighted sequences, hyperintense on cine SSFP compared to normal myocardium, and exhibiting late gadolinium enhancement. The central areas that demonstrate no enhancement correlate with hemorrhagic breakdown products (yellow arrow). Late CMR images showing multiple small myocardial scars as separate and randomly distributed lesions (blue arrow).

Fig. 4

Pathological results confirmed a left atrial myxoma characterized by gelatinous tissue attached to the tumor stalk. The tumor cells included stellate or globular myxoma cells, surrounded by ground substance containing chondroitin sulfate and hyaluronic acid, with numerous red blood cells owing to hemorrhage.

Fig. 5

Repeated cardiac MRI after 3 months showing multiple scars on 4-chamber views and short axis views.