Current Drug Safety, 2011, 6, 343-345 343 1574-8863/11 $58.00+.00 © 2011 Bentham Science Publishers Safety of Intravenous Thrombolysis in Ischemic Stroke Caused by Left Atrial Myxoma Maurizio Acampa *,1 , Rossana Tassi 1 , Francesca Guideri 1 , Giovanna Marotta 1 , Lucia Monti 2 , Gianni Capannini 3 , Alfonso Cerase 2 and Giuseppe Martini 1 1 Stroke Unit, Department of Emergency, Azienda Ospedaliera Universitaria Senese, “Santa Maria alle Scotte” General Hospital, Siena, Italy 2 Unit NINT Neuroimaging and Neurointervention, Department of Neurological and Sensorial Sciences, Azienda Ospedaliera Universitaria Senese, “Santa Maria alle Scotte” General Hospital, Siena, Italy 3 Cardiac Surgery Unit, Department of Cardiac and Thoracic Surgery, Azienda Ospedaliera Universitaria Senese, “Santa Maria alle Scotte” General Hospital, Siena, Italy Abstract: Intravenous thrombolytic treatment represents the gold standard for acute ischemic stroke treatment. However there is some concern to perform this treatment in patients with known cardiac myxomas for the risk of haemorragic complications. Here we described a 63-year-old patient with ischemic stroke due to embolization of atrial myxoma and treated with intravenous recombinant tissue plasminogen activator alteplase. The patient did not show improvement after treatment; 25 days later a brain CT showed an asymptomatic small hemorrhagic infarction, probably due to the large size of ischemic lesion. The lack of response might be explained by the embolization of a large tumor fragment. One-year after cardiac surgery clinical follow-up did not reveal new neurological signs nor symptoms. This case report suggests that systemic thrombolysis is a safe procedure also in patient with atrial myxoma. The efficacy of therapy seems to be related to embolus composition. Keywords: Stroke, atrial myxoma, thrombolysis. INTRODUCTION Atrial myxomas are uncommon cardiac tumors which may present with neurological symptoms or signs in about 30% of patients [1]. Most frequent neurological presentation includes transient ischemic attacks and ischemic strokes, while haemorragic strokes, possibly resulting from rupture of cerebral aneurysms, occur less frequently. The majority of cerebral infarcts are in multiple sites and in both hemispheres but also occlusion of left or right middle cerebral artery has been reported [2]. The purpose of this case report is to describe a patient treated by intravenous thrombolysis for acute stroke due to the embolic occlusion of right middle cerebral artery by left atrial myxoma. CASE REPORT A 63-year-old woman was admitted to the Stroke Unit of our institution because of sudden onset of left limbs weakness. She was alert and oriented. Blood pressure was 180/80 mmHg, heart rate 80 beats/minute, respiratory rate 19/minute, and body temperature 36.5 °C. Chest, abdominal and heart examination were normal (normal S1 and S2 heart sounds without murmurs). She had left-sided hemiplegia, hemianopsia, hypoesthesia, and neglect. National Institute of Health Stroke Scale score (NIHSS) was 19 (NIHSS scale contains 15 items, including level of consciousness, eye movement, visual field deficit, and motor and sensory *Address correspondence to this author at the Stroke Unit, Policlinico ‘S. Maria alle Scotte’, viale Bracci, n.1, 53100 Siena, Italy; Tel: +39(0)577585309; Fax: +39(0)577585307; E-mail: M.Acampa@ao-siena.toscana.it involvement: this scale items are scored by degree of severity using weighted scores and can be used to estimate current clinical status [3]). The patient had a medical history of mild hypertension and hypercholesterolemia. She did not take any drugs and she had never smoked. An ECG showed normal sinus rhythm and chest radiographic findings were normal. Computed tomography (CT) of the brain (Fig. 1a, c) performed two hours after symptoms onset ruled out intracranial acute haemorrhage and showed subtle changes consistent with hyperacute ischemia of the right cerebral hemisphere. There were also areas of low-attenuation density in the left thalamus, and both cerebellar hemispheres mainly in the left side: these findings were consistent with gliotic- malacic changes due to previous vascular events. CT angiography (CTA) of cervico-cranial arteries (Fig. 1b) showed the occlusion of the right middle cerebral artery at its M1 segment, with evidence of collateral vessels. There were no CTA signs of other pathological changes in the extra- and intracranial cervico-cranial arteries. Intravenous recombinant tissue plasminogen activator alteplase was then administered, at 2 hours and 40 minutes after symptoms onset. Administered dose of alteplase was 0.9mg per kilogram body weight (70 mg) infused intravenously over 60 minutes, with 10% of the total dose administered as an initial intravenous bolus. 24 hours later, neurological examination was unchanged, and brain CT showed a large infarction in the right middle cerebral artery territory distribution. A transthoracic echocardiography revealed a large (60 x 20 mm) pedunculated homogenous mass originating from the atrial wall prolapsing through the mitral valve (Fig. 2a). The patient did not undergo cardiac surgery due to the large