We present the results of a 12-year retrospective analysis of 11 patients, eight women and three men, aged 16-76 years, with pathologically documented atrial myxomas. Nine of the 11 patients were found to have a left atrial myxoma; right atrial myxomas were identified in two. Five of the 11 patients (45%) had abnormalities on neurologic examination, and five of five had computed tomographic evidence of nonhemorrhagic cerebral infarction. Neurologic symptoms were the initial presentation in four patients. Six patients reported a history of cardiac disease; eight of the 11 had abnormalities on cardiac auscultation. Echocardiography in 10 patients was diagnostic in all but one. Gated magnetic resonance imaging of the heart in two patients demonstrated myxoma position and movement. Follow-up examinations (varying from 1 month to 7 years after tumor resection) in nine of 11 patients demonstrated no recurrent neurologic symptoms. Cerebral infarction is a common complication of atrial myxomas and may be the presenting feature. Recurrent cerebral emboli before surgery is not uncommon. Cardiac auscultation may be normal, and electrocardiographic changes are often nonspecific. Delayed neurologic events following surgery are rare.

Neurologic manifestations of atrial myxoma. A 12-year experience and review.

Ultrasound was used to determine the presence of free intraperitoneal fluid. Base-line values were obtained by introducing known amounts of fluid into the peritoneal cavities of cadavers and obtaining readings in multiple positions, the right lateral decubitus and hand-knee positions being the most sensitive. As little as 100 ml of fluid could be detected. Ultrasonic patterns changed with repositioning of the patient, confirming the presence of free intraperitoneal fluid rather than loculated collections.

Evaluation of ascites by ultrasound.

An aneurysm is a focal dilatation of an arterial blood vessel. Luminal forces, such as high blood flow, shear stress and turbulence, are implicated in the pathogenesis of intracranial aneurysms, and luminal characteristics, such as sac size and morphology, are usually essential to the clinical decision-making process. Despite frequent clinical emphasis on the vessel lumen, however, the pathology underlying the formation, growth and rupture of an aneurysm mainly resides in the vessel wall. Research on the morphology and histopathology of the vessel wall reveals that intracranial aneurysms do not constitute a single disease, but are a shared manifestation of a wide range of diseases, each of which has a unique natural history and optimum therapy. This Review classifies intracranial aneurysms by vessel wall pathology, and demonstrates that understanding the morphology and pathology of this structure is important in determining the therapeutic approach. The article concludes that aneurysms represent a symptom of an underlying vascular disease rather than constituting a disease on their own.

Intracranial aneurysms: from vessel wall pathology to therapeutic approach

Background and aims: Cardiac myxoma is a rare but important cause of stroke, which affects young people. More recently the diagnosis has been enhanced by the use of echocardiograms. We aimed to review the neurological presentations, including stroke, of cardiac myxoma in this modern era of diagnosis and management.

Methods : Records of patients with neurological presentations at the Austin and Repatriation Medical Centre and The Northern Hospital were retrieved from 1985 to late 2001, using International Classification of Diseases codes for atrial myxoma. Published literature reports were obtained by using Medline search database. An iterative process of bibliography review was utilised to identify reports not found by primary search. Case demographics, neurological presentations, investigations, treatment and outcome were recorded.

Results : From the Austin and Repatriation Medical Centre and The Northern Hospital, 6 cases were reported in detail and 107 cases from the published literature were analysed. The mean age of all cases was 43 (range 6−82). There was a female to male predominance (3:2). While there were overlapping neurological presentations, the most common presentation was ischaemic stroke (83% of all patients) most often in multiple sites (41%). The other presentations included syncope (28%), psychiatric presentations (23%), headache (15%) and seizures (12%). Commonest means of reaching the diagnosis was by echocardiography. The myxoma was surgically resected in 69% of cases. Of all cases, 24% were autopsy reports, almost all prior to availability of echocardiograms (in mid-1970s).

Conclusions : Patients who presented with neurological complications of cardiac myxoma were young and stroke was by far the most common single presentation. Importantly, when all clinical manifestations were considered, almost half were potentially reversible. In recent years, echocardiography has made significant contribution to establishing the diagnosis less invasively. There is uncertainty about the role of anticoagulants. The treatment of choice remains surgical excision, although the timing post stroke is debatable. There is a need for large scale collaborative studies to help refine management strat­egies. (Intern Med J 2004; 34: 243−249)

Neurological manifestations of cardiac myxoma: a review of the literature and report of cases.

A report of 3 cases illustrates the cerebral angiographic findings which can be encountered in left atrial myxoma with cerebral embolization. Since there apparently has been no previous record of the pathological basis of the unusual developments in chronic stages of the embolization, neuropathological findings at autopsy in one patient have been extensively described. Recognition of these angiographic features may be of major significance in establishing diagnosis. To the classical six varieties of aneurysm should probably be added this rare variety, neoplastic, since some of these aneurysms have sufficient remaining elements of the arterial wall to be classified as true aneurysms.

Cerebral angiography in cardiac myxoma. Correlation of angiographic and histopathological findings

Cerebral embolization of tumor tissue is a well known complication in patients with left heart myxomas (11). Surprisingly, cerebral angiography has rarely been employed in evaluation, and, even in the few cases in which it has been performed (2, 3, 6, 15), little discussion of the findings and only one set of reproductions (6) are presented in the literature. The purpose of this paper is to present a short review of this subject and report 2 cases in which angiocardiographic and pathologic demonstration of left heart myxomas were coupled with cerebral angiograms showing cerebral vascular abnormalities. Review Metastatic lesions constitute 90 to 95 per cent of all cardiac tumors, but of the primary tumors approximately 50 per cent are myxomas (13, 14). About 75 per cent arise in the left atrium. The majority of the others originate in the right atrium (14), with only 4 reported in the left ventricle (7, 12, 17, 18). Few typical clinical features exist (4, 5, 8, 9). The lesion may be entirely silent clinica...

Radiologic observations in cerebral embolization from left heart myxomas.

Recognition of the presence or absence of intraperitoneal fluid may be of considerable importance in the evaluation of abdominal disease. The indebtedness of radiologists to the work of Laurell (4, 5) and Frimann-Dahl (3) is difficult to overestimate. There are times, however, when the signs described are hard to apply. Frimann-Dahl was quick to point out the difficulties when the bowel is fluid-filled, when it is distended by a combination of gas and fluid, and even when it is relatively devoid of gas. Because of these problems we have sought a more usable technic of determining the presence or absence of peritoneal fluid. A further consideration of the anatomy of the flank has led us to the lower and lateral margins of the liver, the hepatic angle. Evaluation of the Flank Stripe The roentgen anatomy of the extraperitoneal and muscle plane fat has been described by both Laurell and Frimann-Dahl. These and other authors further state that the intra-abdominal viscera indent and mold the extraperitoneal fat...

Leonard Stoane

Papers

Radiologic observations in cerebral embolization from left heart myxomas.

Hepatic angle in roentgen evaluation of peritoneal fluid.