2024 American Academy of Neurology Abstract Website

Objective:

Present the case of a right atrial cardiac varix causing embolic stroke across a PFO.

Background:

Right atrial masses are a rare source of cardiac embolism leading to stroke. Cardiac varices are masses that can be found in the right atrium and are composed of dilated, thrombosed veins commonly mistaken for cardiac myxomas.

Design/Methods:

Case report

Results:

A 54 year old man presented to a community hospital after being found down by his spouse at home. He was obtunded, had left hemiparesis. CT angiogram demonstrated a basilar artery clot. He underwent a successful endovascular thrombectomy. His TEE with bubble demonstrated a PFO. The remainder of stroke work-up was unremarkable. His RoPE score was 7 and PFO closure recommended. Cardiac catheterization was performed, and a right atrial mass was identified so the initial PFO closure procedure was aborted. Cardiac MRI confirmed the 1cm mass in the right atrium, which appeared consistent with myxoma or fibroelastoma. Cardiothoracic surgery was consulted. Surgical excision of the Right atrial mass with concurrent PFO closure was planned. Intraoperatively, a 1cm blue mass was identified at the base of the septum primum at the IVC junction. Grossly, the mass was consistent with varicose Thebesian vein with laminated calcifications inside. The mass was resected and PFO closed. Pathology report confirmed that the surgical specimen was consistent with endomyocardium, blood clot, and calcified nodules.

Conclusions:

A cardiac varix can lead to paradoxical embolism across a PFO leading to ischemic stroke. Cardiac varix should be considered when a right atrial mass is identified in the evaluation of a stroke patient without traditional vascular risk factors.