Giant Left Atrial Myxoma in a Nonagenarian

of nociceptive cholinergic afferent type C neurons of the trigeminal nerve that relay to the ventromedial spinal trigeminal tract and the adjacent pontine-medullary reticular formation to reach the sneeze-evoking center in the rostral medulla initiates the nasal phase. The respiratory phase begins once inspiratory and expiratory neurons have been recruited, consisting of eye closing, deep inspiration, and forced expiration with glottis closure and increasing intrapulmonary pressure. The center may be bilateral and functionally independent on both sides. There are reports of inability to sneeze secondary to medullary infarction or neoplasm. Our case was remarkable because sneezing paroxysms preceded focal neurological findings, had multiple fits with additional neurological decompensation, and lacked the common features of lateral medullary syndrome. Infarction in this territory could not be excluded because his pacemaker contraindicated magnetic resonance imaging. He sustained infarctions to the left superior cerebellum and right thalamus, lesions not previously associated with sneezing. Cervical artery dissection may occur as a consequence of rigorous sneezing and lead to stroke secondarily. Although vascular imaging was not performed, cervical artery dissection is uncommon in elderly adults. The recurrent sneeze paroxysms in concert with acute neurological deficits also imply that thromboembolism provoked the sneezing. His initial paroxysm may have been from small infarctions along the afferent trigeminal pathway anywhere in the ventromedial descending trigeminal nucleus or in its projections to the medullary “sneeze center,” which led to a disengaged sneeze reflex. Pathological sneezing patterns should be recognized (Table 1), which may lead to a reduction of morbidity. Abrupt paroxysmal sneezing in elderly adults, especially in the presence of cardiovascular risk factors, should indicate the possibility of ischemic stroke, particularly to the lower brainstem. Further reporting of cases or prospectively assessing for sneezing in individuals with stroke could lead to enhanced understanding of this underreported phenomenon, because this symptom may be a warning of potentially neurologically devastating events in older adults, in whom stroke incidence and prevalence is highest.