Case Presentation
A 55 year old female presented to the Emergency Department having woken up acutely short of breath. Prior to admission she had been under investigation for chronic diarrhoea, weight loss and lethargy. She had no prior cardiac history. Plain chest radiograph demonstrated bilateral pulmonary infiltrates and arterial blood gas analysis showed type 1 respiratory failure. The initial working diagnosis was of atypical pneumonia, and endo-tracheal intubation was performed due to worsening hypoxaemia. During transfer to critical care the patient was noted to be dysrhythmic on electrocardiograph (ECG) monitoring.
Over the next 24 hours, the patient’s respiratory function improved however, she was found to have new right hemiparesis and a computed tomography (CT) brain scan diagnosed an acute ischaemic infarction in the left parietal lobe. Aspirin was started and the patient was extubated. Following extubation her respiratory function began to deteriorate again, and the atypical pneumonia screen was negative. Pulmonary oedema was therefore considered as a possible diagnosis and so a FICE scan was performed at the bedside. This revealed a large mass in the left atrium which prompted a CT chest, abdomen and pelvis and trans-oesophageal echocardiography (TOE) as part of the pre-operative patient work-up for cardiothoracic surgery.
The FICE scan demonstrated a large left atrial mass extending into the left ventricle through the mitral valve (Figures a and b). This was best appreciated on the apical four chamber view as demonstrated in Figure a. Further imaging performed by a specialist transoesophageal echocardiographer confirmed a 10cm x 3cm cystic mass (Figure c) resulting in functional mitral stenosis (Figure d) and acute pulmonary oedema. Coronary angiography showed no vessel disease, and the patient was immediately taken to theatre for excision of the mass. The post-operative recovery period was uncomplicated, and the patient was extubated and went on to rehabilitate. Histological analysis showed the tumour was a cardiac angiosarcoma.
The parietal lobe stroke was presumed to be an embolic event secondary to the left atrial tumour. Debris from the left pulmonary vein removed during surgery had the appearance of reactive blood clot. Magnetic Resonance Imaging (MRI) of the brain following surgery showed areas of diffusion restriction in left middle cerebral and posterior cerebral artery territories suggestive of embolic phenomena not visualised on CT scanning.