Mechanical thrombectomy for acute ischemic stroke secondary to left atrial myxoma combined with lower-extremity arterial embolism: a case report
Case Report

Mechanical thrombectomy for acute ischemic stroke secondary to left atrial myxoma combined with lower-extremity arterial embolism: a case report

Mingzhu Feng1 ORCID logo, Wenjun Liang1, Zile Yan1, Songli Zhao2, Jinmian Wu3, Shuiquan Yang1, Gan Chen1,4

1Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People’s Hospital (Sanshui Hospital, Zhujiang Hospital, Southern Medical University), Foshan, China; 2Department of Pathology, Foshan Sanshui District People’s Hospital, Foshan, China; 3Department of Interventional Diagnosis and Treatment Center, Foshan Sanshui District People’s Hospital, Foshan, China; 4Department of Neurology, The Sixth People's Hospital of Nanhai District, Foshan, China

Contributions: (I) Conception and design: M Feng; (II) Administrative support: S Yang; (III) Provision of study materials or patients: G Chen, S Zhao, J Wu; (IV) Collection and assembly of data: M Feng; (V) Data analysis and interpretation: M Feng, W Liang, Z Yan; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Gan Chen, MD; Department of Neurology, The Sixth People's Hospital of Nanhai District, No. 58 Huanghai Road, Foshan 528200, China; Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People’s Hospital (Sanshui Hospital, Zhujiang Hospital, Southern Medical University), Foshan, China. Email: chenggan0303@126.com; Shuiquan Yang, MD. Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People’s Hospital (Sanshui Hospital, Zhujiang Hospital, Southern Medical University), No. 16 West Guanghai Avenue, Sanshui District, Foshan 528100, China. Email: yangshuiquan1969@126.com.

Background: Cardiac myxoma (CM) is the most common primary benign cardiac tumor and is a recognized cause of systemic embolism, particularly ischemic stroke. Although cerebral embolic events are relatively common in patients with CM, the simultaneous occurrence of intracranial and peripheral arterial embolism is exceedingly rare and poses substantial diagnostic and therapeutic challenges.

Case Description: A 43-year-old woman presented with sudden loss of consciousness and vomiting. Neurological examination revealed severe deficits, and imaging demonstrated acute infarctions involving the cerebellum and pons secondary to basilar artery occlusion. Because intravenous thrombolysis was contraindicated, emergency mechanical thrombectomy was performed, resulting in complete reperfusion. Following neurological improvement, further examination revealed acute ischemia of the left lower extremity. Vascular imaging confirmed multiple arterial occlusions involving the popliteal and tibial arteries, and successful reperfusion was achieved through a second thrombectomy procedure. Histopathological analysis of the retrieved embolic material demonstrated myxomatous tissue. Subsequent transthoracic echocardiography identified a mobile left atrial mass, and surgical resection was performed. Postoperative pathology confirmed the diagnosis of left atrial myxoma. The patient recovered well after multidisciplinary management and achieved complete neurological recovery without residual disability at the 3-month follow-up.

Conclusions: CM can cause extensive and simultaneous embolization involving both cerebral and peripheral arterial circulations. In patients with CM-related stroke, clinicians should maintain a high index of suspicion for embolic events in other vascular territories and perform comprehensive vascular assessment when appropriate. Mechanical thrombectomy may represent an effective treatment strategy for selected patients, while timely surgical resection of the primary tumor is essential for preventing recurrent embolic events and improving clinical outcomes.

Keywords: Cardiac myxoma (CM); acute ischemic stroke; mechanical thrombectomy; peripheral arterial embolism; case report

Received: 14 February 2026; Accepted: 08 April 2026; Published online: 25 May 2026.

doi: 10.21037/acr-2026-0041

Highlight box

Key findings

• A 43-year-old woman had coma due to basilar artery occlusion; mechanical thrombectomy achieved complete reperfusion.

• Simultaneous left lower-limb arterial emboli were identified and treated; myxoma was confirmed as the embolic source.

• After myxoma resection, the patient achieved full neurological recovery (modified Rankin Scale 0) at 3 months.

What is known and what is new?

• Cardiac myxoma (CM) is a rare cause of cardioembolic stroke in young patients, with unclear optimal management.

• This case reports rare simultaneous intracranial and peripheral embolism from CM, demonstrating effective sequential thrombectomy and cardiac resection.

What is the implication, and what should change now?

• CM should be considered in young patients with large-vessel occlusion, especially with systemic embolism; multidisciplinary management is key.

• Mechanical thrombectomy may viable for myxoma-related occlusion; comprehensive vascular assessment and early myxoma resection are advised.

Introduction

Background

Cardiac myxoma (CM) accounts for approximately 50–60% of primary benign cardiac tumors, with about 75% arising in the left atrium (1-3). Typical clinical manifestations include intracardiac blood flow obstruction, systemic embolization, and constitutional symptoms (2,4). Systemic embolic events occur in approximately 30–50% of patients, with the central nervous system being the most frequently involved target organ (4-6).

Rationale and knowledge gap

CM-related stroke most commonly presents as cardioembolic large-vessel occlusion, characterized by abrupt onset, severe neurological deficits, and a high rate of disability (6-8). Emboli in CM-related stroke may contain tumor tissue components in addition to thrombotic material, and the efficacy of intravenous thrombolysis in this specific etiology remains uncertain (7). Currently, no specific guidelines are dedicated to the management of acute ischemic stroke secondary to CM; therefore, treatment strategies are mainly extrapolated from general acute ischemic stroke guidelines, and the level of evidence supporting intravenous thrombolysis in this special population remains limited (4).

Recent case reports and small case series have suggested that mechanical thrombectomy is associated with high recanalization rates and favorable functional outcomes in patients with CM-related large-vessel occlusion (6-8). However, CM-associated basilar artery occlusion accompanied by simultaneous multiterritorial peripheral arterial embolism is exceedingly rare.

Objective

This paper reports a rare case of simultaneous basilar artery embolism and lower extremity arterial embolism caused by left atrial myxoma, and summarizes the successful treatment experience, so as to provide a reference for the clinical sequential implementation of mechanical thrombectomy followed by cardiac tumor resection. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0041/rc).

Case presentation

A 43-year-old woman with no significant medical history was brought to the emergency department because of sudden loss of consciousness accompanied by vomiting for 3 hours. On admission, her blood pressure was 128/72 mmHg, heart rate 78 beats per minute, and blood glucose level 5.6 mmol/L. She was comatose, with absent light reflex in the left pupil and sluggish response in the right pupil. Motor responses to painful stimulation were reduced in all four limbs, and the National Institutes of Health Stroke Scale (NIHSS) score was 25. Endotracheal intubation was performed for airway protection. Because clinically significant epistaxis and oral mucosal bleeding occurred following traumatic endotracheal intubation, intravenous thrombolysis was contraindicated and therefore not administered. Cranial CT showed no abnormalities.

Brain magnetic resonance imaging (MRI) showed acute infarctions in both cerebellar hemispheres and the pons (Figure 1A,1B), and magnetic resonance angiography (MRA) revealed basilar artery occlusion (Figure 1C). The procedure was performed under local anesthesia. A right femoral artery puncture was performed, and an 8F guiding catheter was placed in the left vertebral artery. After angiographic confirmation of the basilar artery occlusion (Figure 1D), mechanical thrombectomy was initiated using a Trevo 4 mm × 20 mm stent retriever. The initial attempt with the “SWIM” technique resulted in partial reperfusion but persistent occlusion. After three passes of the stent retriever combined with proximal aspiration using a large-bore intermediate catheter, complete reperfusion [thrombolysis in cerebral infarction (TICI) grade 3] was achieved (Figure 1E), and a large amount of gelatinous thrombus was successfully retrieved (Figure 1F).

Figure 1 MRI and endovascular treatment of basilar artery occlusion. (A,B) Diffusion-weighted MRI showing acute infarctions in both cerebellar hemispheres and the pons. (C) Magnetic resonance angiography demonstrating occlusion of the basilar artery. (D) Digital subtraction angiography confirming basilar artery occlusion. (E) Complete reperfusion after mechanical thrombectomy (TICI grade 3). (F) Gross appearance of the retrieved gelatinous embolus. The red arrows indicate the site of basilar artery occlusion (C,D) and successful recanalization of the basilar artery after mechanical thrombectomy (E). MRI, magnetic resonance imaging; TICI, thrombolysis in cerebral infarction.

After the procedure, the patient gradually regained consciousness and was able to follow simple commands. Both pupils were equal and reactive to light, and muscle strength in all four limbs improved to approximately grade 4. On the second day, physical examination revealed a markedly weakened dorsalis pedis pulse and decreased skin temperature in the left foot (Figure 2A). Duplex ultrasonography demonstrated intraluminal echogenic material with absent flow in the left popliteal, posterior tibial, and anterior tibial arteries (Figure 2B). Lower-extremity angiography showed acute occlusion of the left popliteal artery, tibioperoneal trunk, and proximal segments of the posterior tibial, peroneal, and anterior tibial arteries (Figure 2C,2D). Additional angiographic findings before and after treatment are shown in (Figure 2E,2F). The embolus retrieved from the basilar artery appeared gray-white on gross inspection, and histopathological examination demonstrated myxomatous tissue consistent with CM (Figure 2G-2I).

Figure 2 Peripheral arterial embolism and histopathological findings. (A) Decreased skin temperature and weakened dorsalis pedis pulse in the left foot. (B) Duplex ultrasonography showing intraluminal echogenic material with absent flow in the left popliteal and tibial arteries. (C,E) Lower-extremity angiography demonstrating acute occlusion of the left popliteal artery, tibioperoneal trunk, and proximal segments of the posterior tibial, peroneal, and anterior tibial arteries. (D,F) Successful reperfusion after mechanical thrombectomy. (G) Gross appearance of embolic material retrieved from the basilar artery. (H,I) Histopathological examination showing myxomatous tissue consistent with cardiac myxoma (hematoxylin and eosin staining; magnification ×200). The red arrows indicate the site of acute occlusion in the left popliteal artery (C) and left tibioperoneal trunk (E), and their successful recanalization after mechanical thrombectomy (D,F).

Mechanical thrombectomy of the lower-limb arteries was performed via a left common femoral artery antegrade approach under local infiltration anesthesia. Angiography confirmed extensive thrombus burden involving the left popliteal, tibioperoneal trunk, and proximal anterior tibial, peroneal, and posterior tibial arteries (Figure 2C,2E). A 6-F guiding sheath and catheter were initially used for aspiration, retrieving a small amount of thrombus, but the thrombus was too large to be fully extracted. The setup was exchanged to an 8-F long sheath and guiding catheter, from which approximately 20 g of pale-red thrombus was aspirated. Further aspiration of the distal anterior and posterior tibial arteries was performed using a 6-F Catalyst 6 catheter. Although a small amount of residual thrombus remained in the distal foot arteries, successful reperfusion of the main arterial tree was achieved (Figure 2D,2F).

Following thrombectomy, the patient received therapeutic anticoagulation with subcutaneous low-molecular-weight heparin (LMWH) calcium to prevent recurrent embolism. After confirmation of CM, LMWH was continued as a bridge to surgery. Dual antiplatelet therapy was withheld due to the planned intervention. Supportive care included blood pressure management, high-intensity statin, and standard prophylaxis. LMWH was discontinued preoperatively per protocol.

Transthoracic echocardiography showed a 41 mm × 27 mm left atrial mass with heterogeneous echogenicity, attached to the interatrial septum and exhibiting high mobility on a broad-based stalk (Figure 3A). After multidisciplinary discussion, the patient underwent thoracoscopic resection of the cardiac mass, which was completely excised (Figure 3B). Intraoperatively, the tumor was noted to be gelatinous, friable, and villous in appearance, consistent with a high embolic risk. Postoperative pathology confirmed CM (Figure 3C). The postoperative course was uneventful. Lifelong aspirin was initiated after tumor resection. At the 3-month follow-up, the patient was able to walk independently without neurological deficits, and the modified Rankin Scale (mRS) score was 0. Table 1 provides a timeline of the events.

Figure 3 Cardiac imaging and surgical findings. (A) Transthoracic echocardiography demonstrating a solid mass in the left atrium. (B) Intraoperative view showing complete excision of the cardiac mass. (C) Postoperative histopathology confirming cardiac myxoma (hematoxylin and eosin staining; magnification ×200).

Table 1

Timeline of key clinical events

Timeline Events
Day 1 13:10 Symptom onset
Day 1 14:00 Hospital arrival
Day 1 14:10 Endotracheal intubation
Day 1 14:26 Cranial CT examination
Day 1 15:15 Brain MRI examination
Day 1 16:33 Consent for procedure
Day 1 16:40 Transfer to angiography suite
Day 1 17:20 Right femoral puncture
Day 1 18:14 Successful reperfusion (TICI grade 3) achieved
Day 2 17:29 Identification of limb ischemia
Day 2 18:30 Peripheral thrombectomy
Day 3 10:30 Echocardiography
7 days post-MT Thoracoscopic resection of the left atrial mass was performed.
3 months post-discharge mRS score 0. Patient walked independently with no neurological deficits

CT, computed tomography; MRI, magnetic resonance imaging; mRS, modified Rankin Scale; MT, mechanical thrombectomy; TICI, thrombolysis in cerebral infarction.

All procedures performed in this case were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Key findings

This case report describes the successful management of a 43-year-old woman with concurrent acute ischemic stroke and peripheral arterial embolism, both due to CM. Sequential mechanical thrombectomy for the basilar artery occlusion, followed by treatment of lower-limb arterial occlusions, achieved reperfusion. Histopathology confirmed myxomatous tissue, directly linking the emboli to a left atrial myxoma, which was surgically resected. This multidisciplinary approach resulted in complete neurological recovery (mRS score 0) at 3 months. This favorable outcome is consistent with and lends further support to prior case series, which collectively suggest that a combined endovascular and surgical approach may improve prognosis in patients with CM-related embolic events (6-8).

Strengths and limitations

The primary strength of this report lies in its comprehensive documentation of a rare and instructive clinical scenario: the histologically confirmed, synchronous embolization of both intracranial (basilar artery) and peripheral (lower-extremity) arteries from a CM. The holistic narrative, spanning acute presentation, sequential interventions, definitive histopathology, surgical management, and follow-up, provides valuable insights into a complete multidisciplinary care pathway for such complex, multi-embolic events.

However, as a single-case report, the findings inherently lack generalizability. Furthermore, the optimal timing for peripheral vascular intervention in relation to the neurologic event and the subsequent cardiac surgery remains undefined and is likely to be patient-specific.

Explanations of findings

The clinical and radiographic findings in this patient are directly explained by the pathophysiological mechanisms of CM. These tumors are histologically gelatinous and friable, with a marked tendency for fragmentation or for serving as a nidus for thrombus formation (1,2). The embolic material retrieved in this case, confirmed as myxomatous tissue, exemplifies this mechanism. The abrupt onset of coma was a classic manifestation of basilar artery occlusion, a devastating form of stroke. The subsequent discovery of lower-limb ischemia, though initially overshadowed by the profound neurological deficit, is a testament to the tumor’s embologenic potential and the phenomenon of simultaneous multi-organ embolism (2,6). The positive response to mechanical thrombectomy, despite the tumorous nature of the embolus, suggests that stent retrievers can effectively engage and remove such material. The full neurological recovery was likely contingent upon the rapid restoration of basilar artery flow, followed by the elimination of the embolic source via cardiac surgery, thereby preventing recurrent events and allowing for neural repair.

Comparison with similar research

Our findings are consistent with a growing body of literature comprising case reports and small series that support the efficacy and safety of mechanical thrombectomy for acute large-vessel occlusion stroke secondary to CM (5-7). These publications collectively report high rates of successful recanalization and good functional outcomes, challenging earlier uncertainties regarding the utility of endovascular therapy for tumor emboli. The novelty of the present case lies in the documentation of synchronous, symptomatic embolization to both the posterior cerebral circulation and multiple arteries of the lower extremity. While systemic embolic phenomena are a known characteristic of CM, occurring in 30–50% of cases (4,5), most reported instances involve either cerebral or peripheral events in isolation (Table S1) (1,2,5,7-19). This case underscores the tumor’s potential for causing widespread, simultaneous embolization and highlights the critical importance of a systematic search for emboli in other vascular beds once the diagnosis is suspected. The successful outcome achieved through sequential thrombectomy adds to the evidence base for an aggressive endovascular approach, even in the context of multiple embolic occlusions.

Implications and actions needed

This case highlights the importance of considering CM in the differential diagnosis for young patients with acute large-vessel occlusion stroke, particularly in the absence of conventional risk factors. Once suspected, a comprehensive evaluation for synchronous systemic emboli is warranted. The findings support mechanical thrombectomy may be a viable acute reperfusion strategy, followed by prompt surgical resection of the cardiac tumor to prevent recurrence (1,8). To optimize management, specific guidelines for this rare etiology are needed. Establishing multicenter registries to gather treatment and outcome data would help refine best practices. Further research into the properties of myxoma emboli could also inform and improve endovascular techniques.

Conclusions

For patients with stroke caused by CM, systematic screening for peripheral vascular embolism should be performed in a timely manner. Mechanical thrombectomy may benefit selected patients, and prompt resection of the primary tumor is helpful to prevent recurrent embolism.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0041/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0041/prf

Funding: The study was supported by President Foundation of Sanshui Hospital, Zhujiang Hospital, Southern Medical University, Foshan Science and Technology Bureau (grant No. 2520001002835) and the Foshan 14th Five-Year Plan Key Discipline Foundation, China.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0041/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this case were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/acr-2026-0041
Cite this article as: Feng M, Liang W, Yan Z, Zhao S, Wu J, Yang S, Chen G. Mechanical thrombectomy for acute ischemic stroke secondary to left atrial myxoma combined with lower-extremity arterial embolism: a case report. AME Case Rep 2026;10:117.

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