At Cleveland Clinic, further testing was performed to determine the cause of Sheila's "stroke"—the reason for her sudden numbness and mild expressive aphasia. Sheila's past medical history showed no reported drug or alcohol use, and she was a non-smoker. However, she had suffered migraines with aura for years. Sheila's last pregnancy was two years ago.
Upon transfer to Cleveland Clinic, Sheila's white blood cell count was 21,000, her creatinine was 1.5 and labs showed a CK of 1352, CK-MB of 11 and Troponin T of 0.79 ng/mL. A chest X-ray showed no evidence of infiltrates or effusions. Meanwhile, an ECG showed sinus tachycardia with 1-mm ST depressions and T-wave inversions in the lateral distribution. A repeat echocardiogram confirmed the presence of a severely reduced ejection fraction with multi-territorial wall motion abnormalities, mostly in the apical region. A large atrial mass was discovered in the interatrial septum.
To get a closer look at the heart's valves and chambers, an emergent transesophageal echocardiogram was performed. It revealed a large mass in the left atria (2.5 cm x 2.8 cm x 1.7 cm) with a broad base of attachment to the interatrial septum with multiple front-like projections into the left atrial cavity.
After testing, the differential diagnosis included septic left atrial thrombus, left atrial myxoma, atrial sarcoma or an intra-cardiac foreign body. All of these scenarios could likely result in embolization to her cerebral vasculature, causing the stroke symptoms that prompted Sheila to check in to her local hospital.
The severely reduced ejection fraction was a concern and physicians hypothesized this was the result of multi-vessel thrombotic coronary artery occlusion or a Takatsubo cardiomyopathy. A diagnostic coronary angiogram was performed that revealed completely normal coronary arteries, suggesting the latter diagnosis.
Ultimately, Sheila was diagnosed with left atrial myxoma with embolic complications and Takatsubo cardiomyopathy, which has been linked to stroke as a trigger or complication. This condition was identified because of the characteristic left-ventricle apical ballooning seen on the echocardiogram in conjunction with a normal coronary angiogram. Sheila's case was complex because she presented with two separate, rare diagnoses at the same time.