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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 2  |  Page : 184-185

Multiple fusiform distal aneurysms in an operated case of atrial myxoma: Case report and review of literature


1 Department of Neurosurgery, National Neurosciences Centre, Peerless Hospital Complex, Kolkata, India
2 Department of Radiology, National Neurosciences Centre, Peerless Hospital Complex, Kolkata, India

Date of Submission18-Mar-2013
Date of Decision18-Mar-2013
Date of Acceptance27-Mar-2013
Date of Web Publication29-Apr-2013

Correspondence Address:
Prasad Krishnan
Department of Neurosurgery, National Neurosciences Centre, Peerless Hospital Complex, Kolkata
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.111149

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How to cite this article:
Krishnan P, Rajaraman K, Chowdhury SR, Das S. Multiple fusiform distal aneurysms in an operated case of atrial myxoma: Case report and review of literature. Neurol India 2013;61:184-5

How to cite this URL:
Krishnan P, Rajaraman K, Chowdhury SR, Das S. Multiple fusiform distal aneurysms in an operated case of atrial myxoma: Case report and review of literature. Neurol India [serial online] 2013 [cited 2020 Feb 22];61:184-5. Available from: http://www.neurologyindia.com/text.asp?2013/61/2/184/111149


Sir,

The common neurological manifestation of atrial myxomas is cardioembolic stroke. Rarely intracranial hemorrhage from metastatic myxomatous parenchymal infiltration or rupture of myxomatous aneurysms has also been described. We describe multiple fusiform distal aneurysms in a patient who had been operated for left atrial myxoma.

A 31-year-old male presented with history of two episodes of generalized tonic clonic seizures. He was operated for a pedunculated left atrial myxoma 12 years ago and had an uneventful postoperative period. Detailed general physical examination found a lump in his calf muscle which he said was tender. Cranial computed tomography (CT) scan showed multiple hyperdense lesions in left sylvian and anterior interhemispheric fissures [Figure 1]. CT-angiogram showed fusiform dilation of bilateral distal anterior cerebral arteries, multiple dilations of distal middle cerebral artery branches on both sides and also aneurysmal dilatation of the distal right posterior cerebral artery [Figure 2]. The lesions were deemed to be inoperable and the patient was prescribed antiepileptic drug. Transthoracic echocardiography ruled out any residual or recurrent cardiac lesion. Familial history for myxoma or cerebral aneurysms was negative. CT scan of the lump in the calf muscle showed a discrete soft tissue lesion, isodense with muscle, not attached to bone with peripheral calcification [Figure 3]. Histopathology of the mass was reported as myxomatous lesion. The patient is on follow-up for the last 2 years and has had no further symptoms.
Figure 1: CT scan of brain showing multiple hyperdense lesions in left sylvian and anterior interhemispheric fissures [black arrows]

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Figure 2: CT angiogram showing fusiform dilation of bilateral distal anterior cerebral arteries [red arrows], multiple aneurysmal dilations of distal middle cerebral artery branches on both sides [blue arrows] and aneurysmal dilatation of distal right posterior cerebral artery [green arrow]

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Figure 3: CT [scanogram and axial images] of leg showing a discrete soft tissue lesion, isodense with muscle, not attached to bone with peripheral calcification

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Atrial myxomas are the commonest primary cardiac tumors. [1] Common location is in the left atrium [1],[2] and 26-45% of patients develop neurological symptoms at some stage of the disease. [1] The neurological complications may precede or succeed the diagnosis of the myxoma. In the Mayo clinic series, out of the 74 patients, in 9 (12%) neurological symptoms were the initial presenting feature. [1] Cardioembolic stroke, either due to thrombus or tumor tissue, is the most common neurological complication of atrial myxoma. [1],[2],[3],[4] Other neurological manifestations include intracerebral hemorrhage secondary to parenchymal metastases, [2] seizures, and dementia. [4] Less common is the incidence of cerebral aneurysm formation. [2]

The mechanism of aneurysm formation in these patients is speculative. One hypothesis suggests that embolized tumor tissue blocks the vasovasorum of the intracranial arteries thus predisposing to ischemic weakening of the vessel wall and subsequent dilatation [2],[3] while the other hypothesis holds that tumor emboli occlude the vessel lumen causing scarring and pseudoaneurysm formation. [2],[3] Yet other hypothesis holds that tumor tissue penetrates the intima from within and weaken the intracranial vessel wall [2],[3] as in mycotic aneurysms. Angiographic characteristics of these aneurysms: Multiplicity, fusiform appearance, and distal location lend support to these various hypotheses. Further, the hyperdense appearance of these aneurysms on plain CT scan, supposed to be due to deposition of myxoid matrix [3] would support the third explanation.

Because of the uncertain natural history of these aneurysms, [3],[4] there are no clear guidelines for the management of these aneurysms. [2] These aneurysm can have spontaneous thrombosis, [2] rapid growth, [2] and can remain without growth. There is some data to suggest that cerebrospinal fluid (CSF) interleukin 6 may be a marker for aneurysmal growth in these patients. [2],[3] Both coiling and clipping have been suggested. [3] However, several of these aneurysms by virtue of their fusiform nature and multiplicity cannot be coiled or clipped. The majority opinion is that "stable aneurysms" should be managed conservatively with regular follow-up. [3]

Our patient presented 12 years after removal of the atrial myxoma. The angiographic and non-contrast CT scan findings were consistent with cerebral aneurysms in patients with atrial myxoma. The histology of the leg mass was myxomatous lesion. All these findings support the diagnosis of cerebral aneurysms in this patient were probably due to cerebral embolization of myxomatous tumor tissue.

 
  References Top

1.Lee VH, Connolly HM, Brown RD Jr. Central nervous system manifestations of cardiac myxoma. Arch Neurol 2007;64:1115-20.  Back to cited text no. 1
    
2.Herbst M, Wattjes MP, Urbach H, Inhetvin-Hutter C, Becker D, Klockgether T, et al. Cerebral embolism from left atrial myxoma leading to cerebral and retinal aneurysms: A case report. AJNR Am J Neuroradiol 2005;26:666-9.  Back to cited text no. 2
    
3.Sedat J, Chau Y, Dunac A, Gomez N, Suissa L, Mahagne MH. Multiple cerebral aneurysms caused by cardiac myxoma: A case report and present state of knowledge. Interv Neuroradiol 2007;13:179-84.  Back to cited text no. 3
    
4.Ashalatha R, Moosa A, Gupta AK, Krishna Manohar SR, Sandhyamani S. Cerebral aneurysms in atrial myxoma: A delayed, rare manifestation. Neurol India 2005;53:216-8.  Back to cited text no. 4
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