Myxomatous cause of multiple intracranial aneurysms and cognitive decline: a case report

Abstract

Background: The occurrence of cerebral aneurysm in a case of cardiac myxoma is rare with less than 60 cases reported worldwide. The course of management is still debatable given its rarity. We present a case of multiple intracranial aneurysms secondary to atrial myxoma in a young lady with a brief review of the literature. Case presentation A young lady in her late 30s with a history of right middle cerebral artery territory stroke eight years ago presented with gradually progressive symptoms in the form of holocranial headache, inattention and forgetfulness for the last few years. On neuroimaging, she was found to have multi-territorial lacunar infarcts and multiple intracranial artery aneurysms which was confirmed with a digital subtraction angiogram. A cardiac evaluation revealed a left atrial myxoma. The aetiology of subcortical cognitive decline and intracranial aneurysms was attributed to the myxoma with secondary myxomatous embolism. Other secondary causes were ruled out. She is being followed up medically after resection of the myxoma.

Conclusion: Intracranial aneurysms are rare complications of cardiac myxoma which may present before, concurrent or many years after diagnosis of the myxoma. Nonspecific neurological complaints occasionally are the ominous signs of intracranial aneurysms which mandate a low threshold for neuroimaging in a case of cardiac myxoma. Given the absence of definitive risk factors and unclear natural history, clinical and radiological follow-ups are critical. Learning Points Intracranial aneurysms are rare complications of cardiac myxoma that may present before, concurrent or many years after diagnosis of the myxoma. Special attention must be given to nonspecific neurological complaints with a low threshold for neuroimaging in those with a prior history of cardiac myxoma. Given the absence of definitive risk factors and unclear natural history, clinical and radiological follow-up including conventional angiography and/or magnetic resonance imaging is critical.

Keywords: Atrial myxoma; Intracranial aneurysms; Myxoma; Myxomatous.

Fig. 1

A Right and left ICA anteroposterior view angiograms show the fusiform aneurysm at the right middle cerebral artery bifurcation, along the pericallosal branch of the right anterior cerebral artery, along the distal superior division of the left middle cerebral and the left pericallosal artery. B Selective left vertebral artery angiogram in AP view shows a fusiform aneurysm along the right distal posterior cerebral artery (from the P4 segment, arrow) and a saccular aneurysm along the left proximal superior cerebellar artery (arrowhead). C Right ICA lateral angiogram shows the fusiform aneurysms at the right middle cerebral artery bifurcation extending along the inferior and along the right pericallosal branch of the anterior cerebral artery. Multiple smaller aneurysms at the distal anterior and middle cerebral artery branches are also seen. D Left ICA lateral angiogram shows the fusiform aneurysms along the distal superior division of the left middle cerebral artery and at the distal left pericallosal artery, a branch of the left anterior cerebral artery. R: right; L: left; ICA: internal carotid artery; ACA: anterior cerebral artery; MCA: middle cerebral artery; PCA: posterior cerebral artery; BA: basilar artery; L. VA: vertebral artery

Fig. 2

Volume-rendered images generated from the selective right ICA angiogram (A, C) and the left ICA angiogram (B, D) in anterior oblique views show the fusiform aneurysms along the right MCA bifurcation, the distal superior division of the left MCA and along the distal aspect of pericallosal branches of bilateral anterior cerebral arteries. R: right; L: left; ICA: internal carotid artery; ACA: anterior cerebral artery; MCA: middle cerebral artery

Fig. 3

A Apical 4-chamber 2D echocardiogram showing heterogeneous well-circumscribed left atrial mass attached to the interatrial septum, B A mass lesion was seen in the left atrium, appearing hyperintense on black blood and fluid sensitive (T2/STIR) and hypointense on bSSPF C images, D, E Histopathology of myxoma with myxoma cells in myxoid stroma (D) expressing calretinin (E). [D: Haematoxylin and Eosin, E: Immunoperoxidase, Original magnification = Scale bar]. STIR: short tau inversion recovery; bSSPF: balanced steady-state free precession.