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This is a retrospective, multicenter, case-control study in patients with cardiac myxoma-related ischemic stroke (CM-IS). patients with CM-IS have mild-to-moderate neurologic deficits at the onset of the disease.
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Narrower tumor width, tumors with high-mobility, thrombus on the tumor surface, and lower BNP levels are potential predictors of CM-IS development.
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Prolonged symptoms to operation time (SOT) is a potential predictor of CM-IS recurrence.
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Surgical removal of cardiac myxoma is safe, efficacious, and definitive in patients with CM-IS.
Abstract
Background
Cardiac myxoma (CM) is an important etiology of stroke in young adults, but studies on CM-related ischemic stroke (CM-IS) are limited and conflicting. Hence, we investigated clinical characterizations, risk factors of CM-IS, and short-term survival after surgical resection.
Methods
We performed a retrospective analysis of data from all CM patients at three referral management centers and conducted follow-up examination.
Results
Among 414 CM patients, 402 were recruited for further analysis, including 54 patients with CM-IS and 348 patients with CM without stroke (Non-stroke). In the acute phase, patients presented with NIHSS 3 (interquartile range: 0–10) and clinical presentation comprising neurological, cardiac and constitutional symptoms. Multivariate analysis showed that the factors associated with an increased risk of CM-IS were tumor width < 30 mm [OR = 2.652, 95% CI: 1.061–6.627, P = 0.037], tumors with high-mobility (OR = 2.700, 95% CI: 1.357–5.371, P = 0.005), thrombus on the tumor surface (OR = 1.856, 95% CI: 1.003–3.434, P = 0.049), and lower B-type natriuretic peptide (BNP) levels (OR = 0.995, 95% CI: 0.989–0.999, P = 0.047). The overall three-year survival rate was 95.7% (95% CI: 94.9–96.5) in CM-IS patients who underwent surgery.
Conclusions
CM-IS patients had mild or moderate neurologic deficits with various presentations at disease onset. Narrower tumor width, tumors with high-mobility, thrombus on the tumor surface, and lower BNP levels are potential predictors of CM-IS development. Surgical removal of CM is safe and efficacious in patients with CM-IS.
]. However, the diagnosis of CM is often elusive in young stroke patients owing to its variable clinical manifestations, such as non-specific cardiac, embolic (approximately 50% cerebral embolism), and constitutional symptoms [
]) as independent risk factors for embolism were controversial. More importantly, although the only curative treatment to prevent stroke recurrence is surgical CM resection, with an operative mortality rate of 0%–3% [
]. Therefore, this multicenter case-control study aimed to investigate clinical characterizations and risk factors of CM-related ischemic stroke (CM-IS) and examine the postoperative complications and short-term survival rate.
2. Methods
2.1 Study population
A total of 414 patients with CM were identified in three referral management centers in Beijing, China between January 2010 and December 2020. The initial diagnosis of CM was made by echocardiography or subsequently confirmed by pathology. All patients with CM underwent 2D echocardiography using an EPIQ7c ultrasound imaging system (Philips Ultrasound, Bothell, WA, USA, probe: S5–1 or X5–1, 1.0–5.0MHz). Image loops (≥ 3 s) were digitally stored at three different gain settings (−10, 0, +10dB) to select the optimal image for subsequent off-line analysis using TomTec software (GE Healthcare, Chicago, IL, United States). Patients with ischemic stroke (IS) were diagnosed clinically and on computed tomography (CT) or magnetic resonance imaging (MRI) results, confirmed by two experienced neurologists. Patients with CM-IS were further divided into two subgroups: first-episode CM-IS subgroup (suffering from IS for the first time) and recurrent CM-IS subgroup (suffering from IS twice or more). Patients with transient ischemic attack (TIA), asymptomatic ischemic lesion revealed by brain CT or MRI, cerebral vascular aneurysm without stroke, or stroke caused by other cardiac tumors were excluded from this study. The study was performed in accordance with the Declaration of Helsinki and approved by the local ethics committee of each participating institution. Written informed consent was obtained from all the patients.
2.2 Clinical data extraction
Data in the electronic medical records upon first hospital admission, including demographic information, medical history, clinical symptoms, brain and cardiac imaging using CT or MRI, echocardiography and electrocardiogram, operative reports, medicine use and pathological results, were collected.
Regarding echocardiographic data, CM with high-mobility refers to highly mobile phenomena of myxoma mass on transthoracic or transesophageal echocardiography as described by previous literatures [
]. In addition, we selected 30 mm as the threshold of the size of CM, since two distinct studies revealed that tumor diameter < 30 mm were more frequently seen in patients with CM complicated by cerebral infarction [
Independence in activities of daily living (ADL) was measured by Modified Barthel Index (mBI), which consists of 10 daily activity items and can be analyzed using a total score ranging from 0 to 100. Each item was scored on a 5-level scale, from 1 (completely dependent) to 5 (completely independent) [
After hospital discharge, follow-ups were conducted by trained investigators via face-to-face interviews or phone calls. The main outcomes were complications and mortality, which were monitored for periods lasting 1 month to 10.1 years.
2.4 Statistical analysis
Statistical analyses were performed using SPSS (version 17.0; SPSS, Chicago, IL, USA). Continuous variables are presented as mean ± standard deviation or median [interquartile range (IQR)]. Categorical variables were expressed as percentages. Normally distributed data were analyzed using Student's t-test, and non-normally distributed data were analyzed using the Mann–Whitney U test. Categorical variables were analyzed using the chi-squared test. Binary logistic regression analysis was used to assess the variables associated with determining CM stroke and CM stroke recurrence. Variables demonstrating an association with the outcome at a level of ≤0.05 in univariate analysis were candidates for further multivariate analysis. The Kaplan–Meier method was used to estimate the survival rate after surgical resection of CM. Survival curves were estimated using the Kaplan–Meier method and compared using the log-rank test. Statistical significance was set at P < 0.05.
3. Results
3.1 Patient selection
A total of 414 consecutive patients with a diagnosis of CM were enrolled, of whom 66 were initially diagnosed with ischemic cerebrovascular events (ICVE) and 348 were histologically verified as CM without stroke (Non-stroke). Among the 66 cases with ICVE, their etiologies remain unidentified because the neurological deficits might be caused by transient ischemic attack or other non-CM-related etiologies. After further careful evaluation, one case was diagnosed with transient ischemic attack and 11 cases with other pathological mechanisms were excluded, including 10 cases caused by atherosclerosis and one cardiogenic cerebral embolism caused by atrial fibrillation. Of the remaining 54 cases, 51 with IS and histologically verified CM, and 3 with IS and suspected CM upon cardiac imaging were identified. Finally, after excluding 12 patients who did not meet inclusion criteria, 402 patients were included in the study for further analysis (Fig. 1).
Fig. 1Flowchart describing the enrollment of patients with cardiac myxoma-related ischemic stroke (CM-IS).
Half (50%) of patients with CM-IS (n = 54) were female in the present study. The mean age of the patients was 55.7 ± 12.2 years. In most cases (61.1%, 33/54), ICVE was the first and singular manifestation (i.e., hemiplegia, hypoesthesia, aphasia, conscious alteration, dysarthria, ataxia) of CM-IS, whereas sixteen (29.6%, 16/54) and two (3.7%, 2/54) cases demonstrated further cardiac (i.e., dyspnea, cheat tightness/pain, palpitations, cough, syncope) and constitutional (i.e., fever, asthenia, weight loss) symptoms, respectively. Six patients (11.1%, 6/54) had concomitant embolism to other parts of the body, including one patient (1.9%) with concomitant retinal artery ischemia, one (1.9%) with concomitant coronary embolism, one (1.9%) with concomitant pulmonary embolism, one (1.9%) with concomitant peripheral embolism to the right lower extremity, and two (3.7%) with previous peripheral embolism to the bilateral lower extremity or left upper extremity. Two patients (3.7%) showed secondary partial hemorrhagic transformation limited to isolated cortical and subarachnoid hemorrhagic lesions. In the acute phase, most patients (64.8%, 35/54) presented with relatively mild or moderate clinical deficits, as reflected by the NIHSS scores (3, interquartile range: 0, 10). Of the 54 patients, 45 (83.3%) had a history of one episode of stroke and 9 (16.7%) had recurrent stroke.
Compared to Non-stroke patients (n = 348), patients with CM-IS had more coronary heart disease (16.7% vs. 6.6%, P = 0.011), history or tumor width < 30 mm (74.1% vs. 52.2%, P = 0.003), tumors with high-mobility (77.8% vs. 56.0%, P = 0.013), thrombus on the tumor surface (9.6% vs. 2.6%, P = 0.011), and hyperlipidemia (18.5% vs. 7.2%, P = 0.006), elevated platelet count (245.0 ± 102.5 109/L vs. 212.0 ± 84.7 109/L, P = 0.013) and hemoglobin concentration (120.5 ± 23.6 g/L vs. 109.9 ± 21.6 g/L, P = 0.001), as well as lower B-type natriuretic peptide (BNP) levels [100.3 (IQR: 67.0, 208.5) pg/ml vs. 133.7 (IQR: 57.6, 188.4) pg/ml, P = 0.024] compared to patients Non-stroke patients. The details of the comparisons between the two groups are shown in Table 1.
Table 1Comparison of baseline characteristics between patients with cardiac myxoma-related ischemic stroke (CM-IS) and patients of cardiac myxoma without stroke (Non-stroke). Data are presented as mean ± standard deviation (SD) or Median [interquartile range (IQR)] for continuous variables, and number of subjects (n) and percentage (%), respectively, for categorical variables.
In the acute stage of CM-IS, most patients were neurologically stable, while only 3 patients (5.6%, 3/54) suffered early neurological deterioration (END). Modified Barthel Index (mBI) scores were significantly lower in the CM-IS patients as compared with Non-stroke patients at 90 d (84.2 ± 17.2 vs. 95.7 ± 8.1, P = 0.000), and modified Rankin Scale (mRS) 0–1, 2–3 and 4–5 at 90 d was 70.4%, 24.1% and 5.5% in the CM-IS patients, respectively (Fig. 2).
Fig. 2The comparison of modified Barthel Index (mBI) between patients with cardiac myxoma (CM)-related ischemic stroke (CM-IS) and CM without stroke (Non-stroke), as well as distribution of modified Rankin Scale (mRS) scores in patients with CM-IS. (A) mBI scores were significantly lower in the CM-IS patients as compared with Non-stroke patients at 90 d (84.2 ± 17.2 vs. 95.7 ± 8.1, P = 0.000), and (B) mRS 0–1, 2–3 and 4–5 at 90 d were 70.4%, 24.1% and 5.5% in the CM-IS patients, respectively.
Among the 54 patients with CM-IS, the middle cerebral arteries (MCA) were the most commonly affected area (74.1%, 40/54), followed by the posterior cerebral arteries (37.0%, 20/54), anterior cerebral arteries (14.8%, 8/54), basilar arteries (11.1%, 6/54), and internal carotid arteries (1.9%, 1/54) (Table S1).
There were 24 cases in the basal ganglion (24/54, 51.9%), 22 in the frontal lobe (22/54, 40.7%), 18 in the parietal lobe (18/54, 33.3%), 12 in the temporal lobe (12/54, 22.2%), 10 in the cerebellum (10/54, 18.5%), 6 in the thalamus (6/54, 11.1%), 6 in the occipital lobe (6/54, 11.1%), three in the brainstem (5.5%), and 2 in the insula (2/54, 3.7%) (Table S2).
Multiple infarcts (53.7%, 29/54) were more frequently seen in patients with CM-IS than in those with a single infarct (46.3%, 25/54), and there were no significant differences between the left and right sides in either the anterior (χ2 = 0.987, P = 0.320) or posterior circulation (χ2 = 0.150, P = 0.699). Additionally, patients with CM-IS demonstrated more unilateral cerebral infarcts (78.8%, 42/54) than bilateral cerebral infarcts (22.2%, 12/54)), and there was no difference between the anterior and posterior circulations (χ2 = 0.229, P = 0.865) (Table S3).
3.4 Risk factors of CM-related ischemic stroke
Multiple variables, including basic characteristics, stroke risk factors, echocardiography findings (i.e., left atrium diameter, ejection fraction), laboratory results, tumor features, and medication, were compared between patients with and without CM-IS (Table 1). Of the 33 variables, nine were associated with CM-IS by univariate logistic regression: female [odds ratio (OR) = 0.233, 95% CI: 0.282–0.895, P = 0.001], hyperlipidemia [OR = 1.322, 95% CI: 1.136–6.523, P = 0.014], coronary heart disease [OR = 1.231, 95% CI: 1.038–6.489, P = 0.001], tumor width < 30 mm [OR = 2.085, 95% CI: 1.375–4.988, P = 0.000], tumor with high-mobility [OR = 2.215, 95% CI: 1.186–8.720, P = 0.001], thrombus on tumor surface [OR = 3.142, 95% CI: 1.262–12.198, P = 0.001], platelet count [OR = 1.004, 95% CI: 1.001–1.007, P = 0.015], hemoglobin concentration [OR = 1.022, 95% CI: 1.008–1.035, P = 0.001], and BNP levels [OR = 0.994, 95% CI: 0.990–0.999, P = 0.021].
Four significant variables were retained in the final multivariate logistic regression model followed by backward stepwise variable selection. The factors associated with an increased risk of CM-IS were tumor width < 30 mm [OR = 2.652, 95% CI: 1.061–6.627, P = 0.037], tumors with high-mobility (OR = 2.700, 95% CI: 1.357–5.371, P = 0.005), thrombus on the tumor surface (OR = 1.856, 95% CI: 1.003–3.434, P = 0.049), and lower BNP levels (OR = 0.995, 95% CI: 0.989–0.999, P = 0.047) (Table 2).
Table 2Risk factors of patients with cardiac myxoma-related ischemic stroke (CM-IS) : univariate and multivariate binary logistic regression analysis.
Similarly, multiple variables, including basic characteristics, stroke risk factors, echocardiography findings, laboratory results, tumor features, medication, treatment time, and NIHSS scores were also compared between patients with recurrent CM-IS and patients with first-episode CM-IS. Marked differences in fibrinogen degradation product [1.7 (IQR: 1.4, 2.8) μg/ml vs. 0.7 (IQR: 0.4,1.5) μg/ml, P = 0.007], D-dimer levels [207 (IQR: 131.0, 334.0) ng/ml vs. 169.0 (IQR: 53.0, 328.5) ng/ml, P = 0.019], symptoms to operation time (SOT) [25 (IQR: 4.2, 49.9) months vs. 1.1 (IQR: 0.4, 4.2) months, P = 0.002], and homocysteine levels (23.1 ± 11.9 μmol/L vs. 11.6 ± 4.9 μmol/L, P = 0.000) were found between these two CM-IS subgroups (Table S4).
In univariate analyses, four baseline variables were associated with CM-IS recurrence (Table 3) but only SOT (OR = 1.098, 95% CI: 1.005–1.020, P = 0.038) was retained following backward-stepwise variable selection, in the final binary logistic regression model (Table 3).
Table 3Risk factors of ischemic stroke recurrence in patients with cardiac myxoma-related ischemic stroke (CM-IS): univariate and multivariate binary logistic regression analyses.
3.6 Intravenous thrombolysis and intra-arterial thrombectomy for acute CM-IS
One patient received thrombolysis and endovascular therapy (EVT) at stroke onset two months before surgical resection, without residual neurological deficits. One patient received intravenous thrombolytic therapy with minimal residual neurological deficits, which did not deteriorate. No intracerebral hemorrhage transformation occurred in either patient.
3.7 Postoperative complications
There was no postoperative mortality in 393 patients with CM who underwent surgical resection, and 44 (11.2%) patients underwent postoperative complications, including 13 (25.5%, 13/51) patients in the CM-IS group and 31 (9.1%, 31/342) patients in the Non-stroke group. The most common complication related to surgery was pulmonary infection (5.1%, 20/393), followed by arrhythmia (2.3%, 9/393) and embolism (1.5%, 6/393). However, no marked difference was observed between CM-IS and Non-stroke groups in pulmonary infection [4 (7.8%) vs. 16 (4.7%), P = 0.337], arrhythmia [2 (3.9%) vs. 7 (2.0%), P = 0.404], and embolism [2 (3.9%) vs. 4 (1.2%), P = 0.135]. Additionally, pneumothorax occurred in four Non-stroke patients and valvular heart disease occurred in two CM-IS patients, whereas pulmonary hemorrhage, cerebral hemorrhagic transformation secondary to embolism, and nerve injury occurred in one CM-IS patient, respectively (Table 4).
Table 4Comparisons of postoperative complications between patients with cardiac myxoma-related ischemic stroke (CM-IS) and patients of cardiac myxoma without stroke (Non-stroke).
Among 393 CM patients undergoing surgery, 125 were followed up after hospital discharge, including 23 patients with CM-IS and 102 Non-stroke patients. The median follow-up time was 22.2 (IQR: 6.4, 36.4) months. During the follow-up period, only one patient had a stroke in Non-stroke group, and CM recurred in three patients (3/125, 2.4%). Death was recorded in three patients (one CM-IS case, two Non-stroke cases), with overall one-year and three-year survival rates of 95.7% (95% CI: 94.9–96.5) and 95.7% (95% CI: 94.9–96.5) in CM-IS patients, and 100% and 95.8% (95% CI: 95.0–96.6) in Non-stroke patients, respectively (Fig. 3). Causes of death were heart failure (n = 1), massive cerebral embolism (n = 1), and lung infection (n = 1). We did not observe any significant differences in survival rates between patients with CM-IS and Non-stroke (log-rank P = 0.93). CM-related stroke did not increase the risk of mortality when adjusted for age, gender, and recurrent myxoma (hazard ratio = 1.787, 95% CI: 0.092–34.695, P = 0.701).
Fig. 3Kaplan–Meier plot for survival rate in patients with cardiac myxoma-related ischemic stroke (CM-IS) and CM without stroke (Non-stroke). The overall one- and three-year survival rates were 95.7% [95% confidence interval (CI): 94.9–96.5)], 95.7% (95% CI: 94.9–96.5) in the CM-IS group, and 100%, 95.8% (95% CI: 95.0–96.6) in the Non-stroke group, respectively.
To our knowledge, this is the first multicenter cohort study to determine the clinical features, risk factors, and short-term prognosis of patients with CM-IS. We found that CM-IS patients had mild or moderate neurological deficits with various presentations at the onset of the disease, but they had no characteristic neuroimaging feature. Tumor width < 30 mm, tumor with high-mobility, thrombus on tumor surface and lower BNP levels were significantly associated with increased risk of CM-IS, while prolonged SOT was associated with increased risk of CM-IS recurrence. CM-IS patients had an estimated three-year survival rate of 95.7%, and expired from heart failure, massive cerebral embolism, and lung infection.
Stroke caused by cardiac myxoma is known to mainly affect young women in their third and sixth decades of life [
]. Our study showed no obvious female predominance, with a female-to-male ratio of 1:1. However, age was consistent with that of the CM populations, as reported in a previous study [
]. Concomitant cerebrovascular risk factors, such as hyperlipidemia and coronary heart disease, are common among patients with CM-IS. The incidence of initial and singular ICVE (i.e., hemiplegia, hypoesthesia, aphasia, conscious alteration, dysarthria, and ataxia) in patients with CM-IS was relatively high (61.1%), and most patients had mild to moderate stroke, as reflected by their NIHSS scores; in accordance with two recently published studies [
]. Additionally, the incidence of END during the acute phase of disease is low and a favorable outcome remains at the 3-month follow-up visit, which implies a good prognosis in patients with CM-IS.
To date, the association between tumor type, size, location, and mobility with embolism in patients with CM remains controversial [
]. In this study, significant differences in the proportion of tumor width < 30 mm, tumors with high-mobility and thrombus on the tumor surface were found between CM-IS patients and Non-stroke patients, instead of tumor location, or irregular tumor surface. Our findings are noteworthy, as previous studies reported that myxomas with high-mobility were related to an increased occurrence of cerebral embolism [
]. Nevertheless, the relationship between CM morphology and stroke requires further investigation.
Moreover, elevated platelet count and hemoglobin levels were observed separately in patients with CM-IS. Consistent with our results, previous studies have shown a relationship between platelet count or hemoglobin concentration and increased stroke onset [
]. However, in a recently published meta-analysis by Liu et al., platelet count, white blood cells, and hemoglobin concentration were not associated with embolism in CM patients [
]. Interestingly, lower serum levels of BNP, a well-known marker of cardiac damage and dysfunction, were also observed in patients with CM-IS, suggesting its potential use as a biomarker to differentiate between CM-IS and Non-stroke.
Similar to the previous neuroimaging findings of CM-related stroke [
], we found that single cerebral vessels (mostly MCA) and multiple territory involvements were common in patients with CM-IS, thereby displaying no distinctive neuroimaging feature. Additionally, the most frequently affected areas involve the basal ganglion, frontal, parietal, temporal, and cerebellar regions. The predominantly affected cerebral vessels (MCA) and areas (the basal ganglion, cerebellum, and parietal and temporal regions) correspond well with the clinical presentation of hemiplegia, hypoesthesia, aphasia, conscious alteration, dysarthria, and ataxia. Therefore, we recommend that brain imaging should be performed in all patients with CM presenting with immediate neurological deficits.
In the multivariate logistic model, we identified tumor width < 30 mm, tumors with high- mobility, thrombus on the tumor surface, and lower BNP as factors independently associated with CM-IS, and SOT was associated with CM-IS recurrence. The tumor mobility and morphology are strongly related to CM-related stroke and their prognostic value has been reported in various studies [
], mostly on tumor diameter. In the present study we first adopted two different parameters (i.e., tumor length and tumor width), in an attempt to set up a new two-dimensional tumor size measurement for prediction of CM-IS. As a result, we found that the tumor width < 30 mm, instead of tumor length, was associated with the increased risk of CM-IS. The role of decreased BNP levels in CM-IS remains unclear. Of note, a recent meta-analysis revealed that better cardiac function (class I/II) was at a markedly increased risk of embolism than worse function (class III/IV) [
]. Based on this finding, a plausible explanation is that most embolic groups were diagnosed after an acute embolic event, but the tumor blockage symptoms were relatively fewer, so the overall cardiac function was better than that of the non-embolic group. Indeed, our study demonstrated that the proportion of worse cardiac function (class III/IV) in patients with CM-IS was mildly lower than that in the Non-stroke patients. Moreover, the association of narrower tumor width (< 30 mm) with increased risk of CM-IS further supports our viewpoint. Intriguingly, we found that the risk of CM-IS recurrence increased with the time elapsed between IS and CM surgical resection. Our findings, in accordance with those of a previous study by Stefanou et al. [
], substantiate the view that cardiac surgery should be performed as early as possible from the tumor diagnosis. However, these issues must be addressed further.
Presently, for the acute treatment of CM-related stroke, several case series have reported the safety and efficacy of intravenous thrombolysis [
]. Based on the limited data, the AHA/ASA 2019 guidelines make weak recommendations (Class IIb) on the use of IV alteplase in the treatment of CM patients with severe disabling stroke [
Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American heart association/American stroke association.
]. In this study, one patient received intravenous thrombolysis and another patient received intravenous thrombolysis, followed by thrombectomy, with various levels of improvement of neurological deficits. No signs of intracerebral hemorrhage transformation were observed in either patient. Ko et al. reported surgery for myxoma resection through the right anterolateral mini-thoracotomy approach in 1998 [
]. Postoperative complications included IS, wound infection, arrhythmia, pulmonary infection, pleural effusion, deep venous thrombosis, and myocardial infarction7. In our study, minimally invasive resection was performed, and the most common complications were pulmonary infection (5.1%), arrhythmia (2.3%), and embolism (1.5%); implicative of safety and effectiveness of surgical resection for the treatment of CM-IS. Moreover, the lack of difference in postoperative complications between the two groups once again confirms that surgical excision is a relatively safe and efficacious procedure for treating CM, regardless of the stroke complications.
Previous studies reported that CM patients had good long-term survival after surgical resection [
Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American heart association/American stroke association.
]. In this study, we observed that the three-year survival rate of CM-IS was 95.7%, which was better than the long-term (over five years) overall survival rate in the CM cohort after surgical resection [
]. The cause of death was heart failure, massive cerebral embolism, and pneumonia. Of note, in our data, three patients (2.4%, 3/125) had recurrence, consistent with the recurrence rate of <5% after myxoma resection reported in several previous studies [
]. To address this, some clinicians have proposed that in cases of CM occurring at a relatively young age, with ventricular origin, family history, Carney complex, or multiple myxomas; full-layer wide resection is recommended because of the increased recurrence rate [
]. Nonetheless, further large-scale clinical trials are needed to confirm this hypothesis.
5. Limitations
The present study had some limitations. First, as a retrospective study, the data may be insufficient, for example, lack of known onset time for the myxoma and time interval from onset to physician consultation. Second, this study involved a small number of patients, particularly those with CM-IS. Considering the sample size and number of events, the study may fail to reach statistical power; hence, the findings should be interpreted with caution. Third, selection bias may have existed because of the disparity in patient enrollment between the three medical centers. Finally, the number of patients available for follow-up was small and the follow-up period was relatively short for most patients.
6. Conclusions
In conclusion, patients with CM-IS had mild or moderate neurologic deficits with various presentations at the onset of the disease, but they had no characteristic neuroimaging feature. Single cerebral vessels (mostly MCA) and multiple territory involvements are neuroimaging characteristics of CM-IS. Narrower tumor width, tumors with high-mobility, thrombus on the tumor surface, and lower BNP levels are potential predictors of CM-IS development, while prolonged SOT is a potential predictor of CM-IS recurrence. Surgical removal of CM is safe, efficacious, and definitive in either patients with CM-IS or CM without stroke. As such, our findings undoubtedly will help neurologists and cardiologists identify CM patients at high risk of IS and therefore, prevent the occurrence and recurrence of IS. Nevertheless, prospective randomized controlled studies in selected cases with longer follow-up periods are needed to validate our results.
Funding support
This work was supported by grants from National Natural Science foundation (NSF 81870951 and 82071342).
Author disclosures
All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Acknowledgments
The authors thank all participants for their participation.
Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American heart association/American stroke association.
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