Intravenous thrombolysis in a patient with left atrial myxoma with acute ischemic stroke

Sir,

Thank you very much for your comments and subsequent discussion regarding the article.[1] Our patient had declined to the surgical removal of the myxoma when it was detected during routine screening prior to her stroke. Even during her last follow-up visit she was not willing for the surgery. As we have highlighted there are very few reported cases of left atrial myxoma (LAM) with acute ischemic stroke (AIS) undergoing thrombolysis. Out of the reported 10 patients (apart from our patient) six have undergone intravenous thrombolysis (IVT) and in four of them there was an improvement, one did not improve and one patient bled. Because of small number of patients it is difficult to generalize the utility of IVT, even though it appears to be helpful. The mechanism of stroke in these patients may be due to embolism of the clot or tumor tissue or aneurysmal rupture.[2,3] In our patient, computed tomography (CT) at presentation did not reveal hemorrhage, with subsequent magnetic resonance angiography (MRA) ruling out aneurysm. In our patient Echo showed myxoma with thrombus and she improved initially with IVT, suggesting probably it was blood clot rather than tumorous tissue causing the symptoms. During the window period it will be difficult to ascertain whether the tumor/clot embolism is responsible for the symptoms. Interventional management with chemical and/or mechanical thrombolysis may be thought of; but availability of the facility, expertise, and cost will be a challenge in majority of the hospitals in our country. We conclude by responding that it is a rare situation we may encounter, approach should be individualized to each patient taking into account of hospital setting and patients expectations. Combined care from neurologist and cardiologist will definitely help in better outcome in this condition.