CASE REPORT
atrial myxoma; neurologic emergency, acute CVA

Atrial Myxoma Presenting As Stroke
Atrial myxoma is rare. We report the case of a 54-year-old woman who
presented with findings of a typical acute cerebrovascular accident, which
was found to be caused by emboli from an unsuspected atrial myxoma.
Unrelated aortic regurgitation also was present. Diagnosis was made by
echocardiography. Surgery was performed to remove the tumor; however,
the patient remained with a left hemiparesis. The pitfalls of misch'agnosis
are discussed and the need for early use of echocardiography in the work-up
of stroke victims is suggested. [Barber F, Rosen P, Okin T: Atrial myxoma
presenting as stroke. Ann Emerg Med 11:316-318, June 1982.]

Frank Barber, MD *t*
Peter Rosen, MD***
Thomas Okin, MDt
Denver, Colorado
From Denver General Hospital,* St.
Anthony Hospital Systems,* and St.
Joseph Hospital,* Denver, Colorado.

INTRODUCTION
Approximately one-third of cerebral vascular accidents are due to embolic
phenomena.1 Most frequently these emboli originate from thrombi of cardiac
origin in the presence of atrial fibrillation. Occasionally cardiac tumors are
the source of emboli. ~ Primary cardiac tumors are found in 0.007% of all
autopsies. Of these, 38% are left atrial myxomas. 2 Clinical diagnosis of atrial
myxoma is notoriously difficult, and antemortem diagnosis was missed in
50% to 80% of cases before the advent of echocardiography.3'4
We discuss the pitfalls of misdiagnosis and suggest the need for early use of
echocardiography in the work-up of stroke victims.

Address for reprints: Frank Barber, MD,
Denver General Hospital, 750 Cherokee
Street, Denver, Colorado 80204.

CASE REPORT
A 54-year-old white woman was brought to the emergency department
after awaking that rooming unable to use her left side. There was no history
of headache, previous strokes, or seizures. Her only cardiac history consisted
of a vague recollection of palpitations years earlier which were never evaluated by a physician and were no longer a problem. She thought she may have
been told of a heart murmur, but was uncertain on this point. She was a
diet-controlled diabetic.
On physical examination, the patient was alert and oriented. Her blood
pressure was 180/80 m m Hg; her respirations, 20/min; and her pulse, 80/min
and regular. She was afebrile. Her neurologic examination revealed a dense
left central facial nerve palsy, a fight gaze preference, paralysis of her left arm,
and 1 + strength in her left leg. Sensation was intact. Left toe was upgoing.
Cardiac examination revealed a high-pitched diastolic murmur beginning
with the second heart sound, an accentuated first heart sound, and an early
diastolic sound thought to be an opening snap. The rest of her physical examination, laboratory values, chest film, and electrocardiogram were unremarkable.
A computed tomography scan of her brain was normal initially, but when
repeated one week later, it showed an area of infarction in the distribution of
the right middle cerebral artery. A 24-hour Holter monitor and occuloplethysmography were normal. Echocardiography revealed classical findings
consistent with a left atrial myxoma (Figure 1). Cardiac angiography showed
moderate aortic regurgitation. A tumor mass was not visualized. Pulmonary
artery pressure was 48/18 m m Hg (mean of 31). Wedge pressure was 13 and
aortic outflow pressure was 175/60 mrn Hg.

11:6 June 1982

Annals of Emergency Medicine

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ATRIAL MYXOMA
Barber, Rosen & Okin

Fig. 1. Echocardiography of an atrial
m y x o m a s h o w s d e n s e echoes of
tumor behind mitral valve (MV).
Fig. 2. Atrial myxoma at surgery.
At surgery, a m y x o m a was found
attached to the left atrial septum partially obstructing the mitral orifice
(Figure 2). Removal led to an uneventful recovery. Five weeks after admission, the patient remained with a left
hemiparesis. She was discharged after
six weeks.

DISCUSSION
T h e clinical diagnosis of atrial
m y x o m a is still a significant challenge. The difficulty in diagnosis is
due, in part, to its rarity (25% to 35%
of strokes are due to emboli, and less
than 1% of these are from cardiac
tumorsS), and also because of the variety of presenting signs and symptoms.
Between 50% and 75% of patients
present with congestive heart failure. 34
' From 20 o% to 33 oYo have embolic phenomena [80% of these are cerebral emboli). 3'4 One-third of patients
have constitutional symptoms of fever, malaise, and weight loss. 3'4
The symptoms, of course, depend
on the chamber involved. Symptoms
of congestive heart failure, neurologic
deficits due to emboli, fever, malaise,
and weight loss may be due to endocarditis, mitral stenosis, collagen
disease, or myocarditis. Classically,
auscultatory findings for a left atrial
m y x o m a include an increased first
heart sound and early diastolic murmur coincident with a "tumor plop. ''4
One interesting aspect of our case is
that the predominant finding was a
m u r m u r starting immediately with
the second heart sound, a finding
more consistent with aortic regurgitation. Cardiac catheterization proved
that mild regurgitation was present;
because this finding supported the
auscultatory findings, the correct diagnosis would probably have been delayed significantly without the availability of echocardiography. The use of
cardiac angiography alone in diagnosing atrial myxomas has a false negative rate of 25%, as compared with an
8% false negative rate for echocardiography. 4
A rapid diagnosis and expeditious
corrective surgery can be lifesaving, as
a mortality rate of up to 18% has been
reported ill these patients awaiting
surgery. 6 The post-operative mortality
for these patients is reported to be
52/317

negligible, 7 and should be no higher
than that for cardiac surgery in general.
CONCLUSION
This case demonstrates two important points. The first is a reminder
that thrombosis is only one of several
etiologies for stroke. Most physicians
will think of embolus when a patient
presents with a new tachyarrhythmia
Annals of Emergency Medicine

or has known intermittent atrial fibrillation or a recent myocardial infarction - - all situations in which emboli
are common. But it is easy to overlook
a more subtle source, such as that
found in this case. The murmur was
not identified on initial examination,
but only on re-examination in a quieter setting outside the emergency department.
The second point is a further dem11:6 June 1982

onstration of the usefulness of the
e c h o c a r d i o g r a m . In this case, the
echocardiogram was the only way to
make the diagnosis preoperatively. As
discussed, a delay in making this diagnosis can be costly. The availability,
relatively low cost, and non-invasive
nature of echocardiography make it a
procedure worth using early in the
work-up of stroke victims. Perhaps
echocardiography should be done in
the emergency department or in the
radiology department along with CT
scan as the patient is being admitted,
especially in young patients in w h o m

11:6 June 1982

severe thrombolic disease is less prevalent.

REFERENCES
1. Goldstein RJ, Bleich HL, Caplan LR:
Computer stroke registry and diagnosis
program. Read before the American
Academy of Neurology Annual Meeting,
Bal Harbour, Florida, May 1975.
2. O'Neil MB, Grehl TB, Hurley EJ: Cardiac myxomas: A clinical diagnostic challenge. Am J Surg 138:68, 1979.
3. Bulkley BH, Hutchins GM: Atrial myxomas: A fifty-year review. A m Heart J

Annals of Emergency Medicine

97:639-643, 1979.

4. Sutton MG, Mercier UA, Lie JT: Atrial
myxomas: A review of clinical experience
in 40 patients. Mayo Clin Proc 55:371-376,
1980.
5. Alpers BJ, MancoU EL: Clinical Neurology. Philadelphia, FA Davis, 1971, p 222.
6. Syrabas PN, Hatcher CR, Gravanis MB:
Myxoma of the heart: Clinical and experimental observations. Ann Surg 183:
470, 1976.
7. Glenn WWL, Liebow AA, Lindskog GE:
Thoracic and Cardiovascular Surgery With
Related Pathology, ed 3. New York, Apple-

ton-Century Crofts, 1975, p 1126.

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