Midline shift, devoid of obvious gadolinium enhancement. Axial T WI (A), axial T WI (B), FLAIR (C), axial (D), sagittal (E), and enhanced T WI and axial SWI (F).the cardiac myxoma be removed instantly by means of openheart surgery. On the other hand, she declined to undergo cardiac surgery on account of private concerns. Then, 43 days following radiosurgery, the patient was readmitted to our hospital with symptoms of dizziness, nausea, and vomiting, in addition to an upper motor kind of hemiparesis (power grade 3). A cranial MRI revealed severe brain edema without having contrast enhancement and mild midline shifting. A diffuse weighted image (DWI) identified huge bilateral cerebellar hemisphere infarction (Figure 7). At this point, the patient finally agreed to our recommendation to undergo cardiac surgery. Right after considering the possibility of metastatic recurrence, risk of embolisms and aneurysms triggered by cardiacmyxoma, and evidence that chemotherapy can kill myxomatous cells (12), we suggested that the patient receive our experimental chemotherapy regimen (temozolomide 150 mg/m2 for five days). The patient underwent cardiac surgery to eliminate the atrial myxoma on August 21, 2019. The single gelatinous mucinous tumor discovered inside the left atrium was 40 30 20 mm in size. The HE report was suggestive of a myxomatous lesion with hemorrhaging (Figure 4C), consistent with cerebral metastatic lesions (Figures 4A, B). However, some earlier circumstances report that equivalent numerous brain metastases have been shown in Myxofibrosarcoma patients (13, 14). Within this way, differential diagnosis ofFrontiers in Neurologyfrontiersin.orgMa et al../fneur..FIGUREA massive bilateral cerebellar hemisphere infarction was identified on multiple panel of T -weighted (upper) and di use weighted image (below).FIGURE(A ) Hematoxylin and eosin staining showing the cardiac myxoma attached for the atrial wall (A) and also the enrichment of smaller plump spindle to ovoid tumor cells with abundant eosinophilic cytoplasm and minimal cytologic atypia (B) increasing in aggregates and embedded inside the myxoid stroma (C). Scale bar = . (D, E) Immunohistochemical staining showing that myxoma cells express CD (D) but usually do not express SMA (E).Secoisolariciresinol Biological Activity Scale bar = .Veratridine supplier (F) Immunohistochemical staining of Ki showing that myxoma cells are with incredibly low proliferation index.PMID:24190482 Scale bar = .myxofibrosarcoma have to be excluded to conduct a certain diagnosis of myxoma. Myxofibrosarcoma inside the heart has been reported to become composed of mitotically active, pleomorphic, and hyperchromatic spindle cells enmeshed within a myxoid stroma and infiltrate the neighboring myocardium. These neoplastic cells are negative for vascular markers and muscular markers (13, 15). We have performed hematoxylin and eosin staining and immunohistochemical evaluation for differential diagnostic analysis. Within this case, the neoplasm is composed of little stellate to plump spindle cells with abundant eosinophiliccytoplasm and the stroma is myxoid (Figures 8A ), there is no cytologic atypia nor improved mitotic figures, supporting the classical histological features of cardiac myxoma (Figures 8AC). Immunohistochemical staining showed that myxoma cells in this case very express vascular marker CD34 (metastatic cerebral site: Figure 4D, cardiac web page: Figure 8D), which can be not express by myxofibrosarcoma cells. Nevertheless, these cells do not express the smooth muscle marker SMA or Desmin (Figure 8E). Proliferation index of myxoma cells within this case is extremely low, i.e., about 1 (Figure 8F).