Case Presentation:
A 56 year old female with history of atrial myxoma resected two years prior presented to a tertiary care hospital with several episodes of brief, self-resolving, bilateral upper and lower extremity jerking movements over the past two weeks. The seizure-like activity was associated with transient aphasia, but she denied any prior history or other concomitant symptomology. While in the ED, staff witnessed generalized tonic clonic movements and initiated a diagnostic workup. Computed tomography (CT) of the head revealed multiple intracranial lesions with the largest being in the right frontal region. An electroencephalogram (EEG) was negative for epileptiform activity. Transesophageal echocardiogram (TEE) effectively ruled out thromboembolic source. MRI of the head showed bilateral internal carotid artery aneurysms and a 12 x 8 mm hypodensity on the surface of the right middle frontal gyrus with internal enhancement following contrast administration, suggestive of a cavernoma. There were associated areas of hemorrhage, and additional lesions consistent with cavernomas of the left occipital and left parietal lobes. Neurosurgical consultation service was informed and recommended additional imaging prior to intervention. CT of the chest, abdomen, and pelvis revealed no primary malignancy as a source of metastasis. A 24-hour EEG demonstrated right frontal epileptiform potentials and two focal seizures of right central origin consistent with focal epilepsy. She was started on intravenous dexamethasone for cerebral edema and levetiracetam for seizure prophylaxis. At this time, the decision was made to pursue a right frontal craniotomy with mass resection. Pathology results identified the lesion as myxomatous, likely tumor embolus from her atrial myxoma. Follow up imaging at one month, four months, and eight months showed stable encephalomalacia with no acute changes.
Discussion:
Atrial myxomas are the most common type of benign cardiac tumors, usually considered to be curative after surgical excision. We present a rare case, where a patient presented with cerebral metastasis 2 years after resection of the atrial myxoma. Systemic embolism of myxoma fragments is well documented, nearing an incidence of 50%, with half involving the brain. However, cerebral metastases presenting as mass lesions is among the rarest of clinical manifestations; only 17 cases have been reported in the literature.
Conclusions:
Our case highlights the importance of long-term vigilance and monitoring in patients with seemingly benign tumors, even after excision. Given the potentially grave consequences of this condition, it is imperative that providers consider metastasis as an etiology of neurological presentations in people with history of atrial myxoma, no matter how remote.