We present a case of a patient initially diagnosed as a cryptogenic stroke, but was subsequently found to have an atrial myxoma after a transient ischemic attack ten months later.

54-year-old African American man presented with sudden onset left hemiparesis (HP). CT and CTA head and neck revealed occlusion of the distal middle cerebral artery (MCA) branches along with sub-occlusive thrombus at the tip of the basilar artery with distal refilling of bilateral posterior cerebral arteries. MRI brain revealed scattered infarcts in left MCA territory, no acute infarcts in the posterior circulation. TEE was unremarkable, and an implantable loop recorder (ILR) was placed prior to discharge. Ten months later, he developed worsening left HP and hemoptysis; stroke work-up was repeated. Repeat MRI brain did not show any new infarcts; no arrhythmias were detected on ILR. Repeat TTE revealed a left atrial myxoma measuring 4.2 x 2.2 cm.

Our case demonstrates the challenge in diagnosing left atrial myxomas. We hypothesize that failure to detect the atrial myxoma during the initial admission, despite the high sensitivities of both TTE and TEE, may have been due to the small size of the atrial myxoma. This case illustrates the importance of repeating the cardiac portion of the stroke etiology work-up in patients with recurrent vascular events and a concern for a central source of embolization.