Local Thrombolysis for Successful Treatment of Acute Stroke in an Adolescent with Cardiac Myxoma

Abstract

Intracardiac myxomas are the most common benign cardiac tumors in adults. They are a rare source of cardiogenic embolisms and sudden death, especially in young patients. This report describes the case of a male adolescent who presented with right-sided paresis and aphasia. Magnetic resonance imaging of the brain revealed an ischemic stroke without evidence of acute bleeding. Intra-arterial local thrombolysis was immediately started. An echocardiographic screening after successful thrombolysis with a remarkable recovery of symptoms detected a thrombotic-like mass in the left atrium. The mass was excised surgically, confirmed as a benign atrial myxoma, and the patient was discharged with restitution ad integrum. Thus, contrary to some critical reports, thrombolytic therapy for acute ischemic strokes due to atrial myxomas may be safe and highly effective.

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

“…403 Although tumoral emboli would not be expected to respond to fibrinolysis, thrombotic emboli would be responsive, as illustrated by case reports of recanalization in response to local, intra-arterial instillation of fibrinolytics. 404,405 There have been at least 15 case reports of patients with atrial myxoma treated with intravenous fibrinolysis with alteplase. [406][407][408][409][410] In 1 case, comparison of pretreatment magnetic resonance angiography and posttreatment transcranial Doppler and catheter angiography showed recanalization.…”

Mechanical Endovascular Recanalization in a Patient with Middle Cerebral Artery Occlusion by Tumorous Emboli Originating from Cardiac Myxoma

“…2) Thrombolytic therapy for main cerebral arterial embolic occlusions associated with cardiac myxoma was reported in 12 cases, of which 8 cases were by IV rt-PA, 3,[6][7][8][9][10][11][12] 2 cases by IA rt-PA, 4,5) and 2 cases by Urokinase. 17,18) Out of these 12 cases, the treatment was effective in 8 of them [3][4][5][6]8,10,11,17) and not in 4. 7,9,12,18) Although, the tumorous embolus was suggested not to be indicated for rt-PA treatment, 6) favorable outcomes were reported in some of these cases.…”

“…2) Although some cases were successfully treated by recombinant tissue-plasminogen activator (rt-PA) for acute embolic stroke associated with cardiac myxoma, [3][4][5][6][7][8][9][10][11][12] thrombolytic therapies did not seem to be effective for tumorous type of emboli. Garcia et al 13) treated two cases with cardiac myxoma emboli by mechanical endovascular thrombectomy using Solitaire FR Device (Ev3, Plymouth, Minnesota, USA) and Trevo (Concentric Medical, Mountain View, California, USA).…”

Is It Safe to Proceed with Thrombolytic Therapy for Acute Ischemic Stroke in a Patient with Cardiac Myxoma Case Report and Review of the Literature

“…Eight previous reports presented patients with acute ischemic strokes and associated cardiac myxoma treated with thrombolytic therapy [3,4,5,6,7,8,9,10]. The majority of those patients (6) were treated with alteplase, 4 of which received it intravenously [3,4,5,6], and 2 intra-arterially [7,8].…”

“…The majority of those patients (6) were treated with alteplase, 4 of which received it intravenously [3,4,5,6], and 2 intra-arterially [7,8]. The 2 remaining reports used intra-arterial urokinase [9,10].…”