Nikita Jain

I am a provisional advanced trainee in general medicine with an interest in Infectious diseases and neurology. I trained at Otago, and am currently working in Palmerston North hospital, attempting to finish up the last leg of the clinical exam. When not studying I like to travel, read and spend time with my partner and 2 cats. 

---

Cardiac Myxoma As A Rare Cause Of Embolic Stroke Effectively Treated With Intravenous Tenecteplas

Case
A 50-year-old woman presented with sudden onset vertigo, vomiting and right arm incoordination. On examination, she was drowsy but rousable to voice, had global aphasia, bilateral internuclear ophthalmoplegia and right upper limb ataxia. The National Institute Health Stroke Score (NIHSS) was 13. CT angiography of the head and neck excluded haemorrhage, arterial occlusion or dissection. Intravenous Tenecteplase was administered at 90 minutes post symptom onset. Laboratory markers including young stroke screen and electrocardiogram were unremarkable.
NIHSS was 1 on assessment the following day. MRI brain showed acute multi-territory infarcts. Transoesophageal echocardiogram demonstrated two left atrial (LA) masses originating from the interatrial septum. CT pulmonary angiogram showed a 44.5mm LA mass. The patient underwent excision of the mass. Histology confirmed features of cardiac myxoma (CM) with admixed fibrinoid and platelet material on the surface. Two weeks following admission, she was discharged home independently mobile.

Discussion
CM is rare and should be considered in patients presenting with multi-territory ischaemic strokes. Emboli consist of tumour fragments or surface thrombotic material, the latter responsive to thrombolytic therapy. The diagnosis is typically made by echocardiography.  With early surgical excision, stroke recurrence rate falls to 5%, in contrast to half of medically managed patients.
10% of cases of CM are associated with autosomal dominant conditions e.g., Carney complex, therefore first-degree relatives require screening.

Conclusion and clinical practice point
There are currently no guidelines on the management of CM related strokes. This case, along with other cases in the literature suggest thrombolysis (including Tenecteplase) and thrombectomy is safe and effective.