Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Recurrent stroke in a patient of lung cancer without pulmonary mass

Recurrent stroke in a patient of lung cancer without pulmonary mass Rationale: Repeated occurring stroke in short intervals with hypercoagulability is unusual so in such cases the conventional vascular risk factors might not be the causes of stroke. Patient concerns: We have presented a case of 60-year-old male presenting with recurrent stroke due to thrombophilia. Diagnoses: Lung cancer was detected by superficial lymph nodes ultrasound and further pathological examination. Interventions: The patient suffered a recurrent stroke and he had persistently high level of D-dimer which suggested the diagnosis of thrombophilia, thus, he was treated with low-molecular-weight heparin. Unfortunately, the treatment was not effective for the patient and he died before any other treatments could be administered. Outcomes: Despite anticoagulant therapy, the patient suffered multiple episodes of stroke and ultimately died. Lessons: This case of recurrent stroke with coagulation disorders without evidence of cancer in imaging and blood test is rare. So in a stroke patient, we should consider malignancy or metastasis as a differential diagnosis as it may be the first manifestation of active cancer elsewhere. Abbreviations: ADC = apparent diffusion coefficient, CT = computed tomography, DWI = diffusion-weighted imaging, MRA, MRV = magnetic resonance angiography and venography, MRI = magnetic resonance imaging, PT-INR = prothrombin time- international normalized ratio, SWI = susceptibility-weighted imaging, TF = tissue factor. Keywords: lung cancer, radiological features, recurrent stroke, thrombophilia 1. Introduction infarction.Furthermore, theincidenceof cerebral infarction in lung [4] cancer is 1.43 times higher than it is in normal population. Stroke is the second most common cause of death and major cause However, as a primary manifestation in a tumor patient, stroke is [1] of disability worldwide. Referring to etiologies of stroke, over rare and is difficult to be identified in clinical practice, especially for [2] 150 potential causes have been listed. Apart from conventional those patients without visible mass. Here we report a rare case of vascular risk factors, cancer could play an important role in recurrentstroke with lungcancer withoutvisible solidmass in lung. patients’ vulnerability to stroke. Previous study has demonstrated that stroke in cancer patients is not rare during its clinical course, [3] presenting in up to 15% of patients. In addition, about 20% to 2. Case report 40% of cancer patients suffering from cerebral infarction lack A 60-year-old male was brought to the emergency department of [4] conventional stroke risk factors. Lung cancer is the most a local hospital for a sudden onset of vertigo, blurred vision, and common type of cancer, with the highest incidence of cerebral left-hand disability. A brain computed tomography (CT) scan was advised and admitted in the hospital. No abnormality was Editor: N/A. detected in the CT scan and the patient was diagnosed as acute cerebral infarction and treated with conventional cerebral The authors state that this study does not involve ethical committee approval, nor does it involve patient consent. vascular therapy. The symptoms had completely resolved with Funding: This study was funded by National Natural Science Foundation of China treatment so the patient was discharged from the hospital. (grant no. 81300940). However, these symptoms reoccurred twice after 7 days and 10 The authors have no conflicts of interest to disclose. days, respectively. On the 13th days, the symptoms reappeared Department of Neurology, Zhongnan Hospital of Wuhan University, Wuchang along with vision impairment and headache. Additionally, his District, Wuhan City, Hubei Province, People’s Republic of China. repeat brain CT scan showed bilateral cerebellum hemorrhagic Correspondence: Yan Xu, Department of Neurology, Zhongnan Hospital of infarction. The patient was then referred to our hospital. Our Wuhan University, No.169 Donghu Road, Wuchang District, Wuhan City, Hubei neurological evaluation revealed vague and dysmetria to the right Province, People’s Republic of China, 430071 (e-mail: shennei@outlook.com). side in finger-nose test. Diffusion-weighted imaging (DWI) and Copyright © 2018 the Author(s). Published by Wolters Kluwer Health, Inc. apparent diffusion coefficient (ADC) exhibited multiple acute This is an open access article distributed under the Creative Commons infarctions and a mixed signal in the left-occipital lobe. Attribution-NoDerivatives License 4.0, which allows for redistribution, commercial Susceptibility-weighted imaging (SWI) showed hemorrhagic and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author. infarcts in the left-occipital lobe and small hemorrhage lesions in bilateral corona radiata. MRI T2 FLAIR shows old lesions in Medicine (2018) 97:5(e9815) the right-frontal lobe and new lesions in bilateral occipital lobe Received: 29 November 2017 / Received in final form: 16 January 2018 / Accepted: 17 January 2018 and corona radiata. Whereas magnetic resonance angiography and venography (MRA, MRV) displayed no abnormality (Fig. 1). http://dx.doi.org/10.1097/MD.0000000000009815 1 Wang et al. Medicine (2018) 97:5 Medicine Figure 1. (A) MRI diffusion-weighted imaging sequence shows hyperintensity in the right cerebellum, bilateral hippocampus, occipital lobes, frontal and parietal lobes (thin arrow), a mixed signal in the left-occipital lobe (coarse arrow). (B) MRI T2/fluid-attenuated inversion recovery shows hypointensity in the right-frontal lobe (arrow). (C) MRI susceptibility-weighted imaging sequence shows hypointensity in the left-occipital lobe, bilateral frontal, and parietal lobes (arrow). (D) Magnetic resonance angiography (MRA) shows normal arteries. (E) Magnetic resonance venography (MRV) shows normal veins. MRA=magnetic resonance angiography, MRI=magnetic resonance imaging, MRV=magnetic resonance venography. In magnetic resonance imaging (MRI), new and old lesions occipital lobe. A repeated MRI showed increase in size of were seen in the involved cerebral portion along multiple vascular hemorrhagic infarction in the right-occipital lobe (Fig. 2). territories in both the anterior and posterior circulation. There Since, cardiac embolism is the most common cause for cerebral was no past history of common vascular risk factors and heart embolism, we performed echocardiography, holter monitor, and diseases, especially atrial fibrillation. Based on these findings, we foaming experiment to screen for underlying heart diseases considered emboli to be etiology of recurrent stroke. At the same (endocarditis, arrhythmia, particularly atrial fibrillation, and time, blood tests showed coagulation disorders with evaluated patent foramen ovale) which may induce the formation of prothrombin time-international normalized ratio (PT-INR) embolus but all these tests were normal. Vascular ultrasound was (1.45), evaluated D-dimer (2522 ng/mL), reduced antithrombin done to rule out deep vein thrombosis of lower extremities and (73%), and evaluated fibrin/fibrinogen degradation products thrombus was not found in lower extremity vessel. Therefore, we (45.75mg/mL), which suggested thrombophilia. The patient was supposed thrombophilia to be the reason of embolism while its given symptomatic treatment including mannitol dehydrate pathogenesis of was unclear. Due to mutilple etiology of therapy and removal of oxygen free radicals, and low- thrombophilia, likely systemic diseases such as connective tissue molecular-weight heparin was added for thrombophilia. Regard- disorder and cancer were taken into account. The laboratory less the treatment, the abnormal clotting and recurrent stroke workup for tumor markers, immune disorders, and infectious continued. The patient’s condition got worse and had paroxys- diseases were within normal limits. Additionally, there was no mal aggravating left-limbs disability. The left-limbs disability was family history of hypercoagulability, so thrombophilia due to partially relieved after half an hour. An emergency brain CT connective tissue diseases or inherited thrombophilia was un- performed showed suspicious hemorrhagic infarcts in bilateral likely. Cancers usually companies abnormalities in coagulation, Figure 2. (A) The brain CT scan shows suspicious hyperdense zones in bilateral occipital lobe. (B) Repeated MRI T2/fluid-attenuated inversion recovery shows an increasing mixed signal in the right-occipital lobe (arrow). CT=computed tomography, MRI=magnetic resonance imaging. 2 Wang et al. Medicine (2018) 97:5 www.md-journal.com Figure 3. (A) Superficial lymph nodes ultrasound shows swollen lymph nodes (arrow). Figure 5. Lymph node biopsy shows tumor cells are similar in size, the nucleus is round or oval, much of the nuclear chromatin is deeply stained (high magnification, hematoxylin, and eosin stain). so, although with normal tumor markers, further examination were carried out to rule out the diagnosis of malignancy. Bone marrow aspiration was done to screen for hematological cancer. that induced the recurrent stroke. The patient again had sudden Simultaneously, thoracic and abdominal CT scan, along with headache, nausea and vomiting and was agitated. His brain CT prostate ultrasound was also done. These test results were scan showed an extensive cerebral hemorrhage (Fig. 6). The normal. As evident, though a primary mass could not be located, patient died after 1 week. tumor cell may spread via the lymphatic system. So, superficial lymph nodes ultrasound performed revealed enlarged lymph 3. Discussion nodes in bilateral cervical, axillary, and inguinal region (Fig. 3A). Unfortunately, when the lymph node biopsy was planned, the We illustrated a case of recurrent stroke with thrombophilia patient had a new episode of stroke and he was completely caused by lung cancer, which was diagnosed by pathological blinded and his left limbs were paralyzed. Along with that he had examination, without any evidence in blood tests or chest CT frequent episodes of nausea and vomiting. The repeat enhanced scan. The brain MRI showed lesions involving multiple vascular MRI revealed new infarction in bilateral occipital lobe and territories in both the anterior and posterior circulation (bilateral parietal lobe and there was no obvious enhanced signal intensity middle cerebral artery and bilateral posterior cerebral artery, (Fig. 4). Once the patient was stable, lymph node biopsy was posterior inferior cerebellar artery) with co-existing new and old done and the result stated supraclavicular lymph node with lesions. Based on these points, we considered embolism to be the cause of recurrent stroke. Cardiac causes tumors and coagulation metastatic carcinoma. Immunohistochemistry results of tumor disorders because thrombophilia are common reasons of cell were: CD117 (), CD20 (), CDX2 (), CK7 (+), NapsinA embolism. Thrombophilia has an inherited or acquired predis- (+), OCT3/4 (), PLAP (), SALL4 (), TTF-1 (+), VILLIN (), position to thrombosis. Thrombophilia is not a disease itself, but a-inhibin (), Ki-67 (positive rate 60%), all of which suggested may be associated with other diseases (e.g., cancer), drug lung cancer (Fig. 5). In conclusion, it was the occult lung cancer Figure 4. The second repeated MRI diffusion-weighted imaging sequence shows hyperintensity in bilateral occipital lobe, frontal, and parietal lobes (arrow). MRI= magnetic resonance imaging 3 Wang et al. Medicine (2018) 97:5 Medicine in acute ischemic stroke patients with active cancer. For cancer patients with venous thromboembolism, treatment with low- molecular-weight heparin is the preferred agent based on the [10,11] [12] findings of large clinical trials. Similarly, Jang et al have reported that in patients with cancer-associated stroke, the D- dimer levels and the risk of recurrence decreased with enoxaparin administration. On the contrary, D-dimer levels and recurrent stroke were not prevented in spite of giving low-molecular-weight heparin in our case, which was unusual. Persistently high level of D-dimer indicates that the recurrent stroke may be related to tumor emboli and not the thrombus. As for ultimate extensive intracranial hemorrhage, which might be related to the metastatic tumors damaging vessel walls or abnormal clotting, the cause is unclear as autopsy was not done. 4. Conclusions Our case highlighted that recurrent stroke may be the first clinical manifestation for patients with metastatic tumor even without visible mass entity, particularly without conventional vascular risks factors. Tumor screening such as PET scan and lymph node examination are essential especially in the absence of solid tumor. References Figure 6. The repeated CT scan shows hyperdense zone in the right-medial temporal lobe. CT=computed tomography. [1] Donnan GA, Fisher M, Macleod M, et al. Stroke. Lancet 2008; 371:1612–23. [2] Dimitrovic A, Breitenfeld T, Supanc V, et al. Stroke caused by lung cancer invading the left atrium. J Stroke Cerebrovasc Dis 2016;25:e66–8. [3] Taccone FS, Jeangette SM, Blecic SA. First-ever stroke as initial exposure (e.g., oral contraceptives) or other conditions (e.g., presentation of systemic cancer. J Stroke Cerebrovasc Dis 2008;17: pregnancy or postpartum), and is known as acquired thrombo- 169–74. [4] Xie XR, Qin C, Chen L, et al. A clinical study on the pathogenesis of lung philia. Meanwhile, genetic defect in coagulation function may [5] cancer-related cerebral infarction. Zhonghua Nei Ke Za Zhi 2017;56: also cause thrombophilia. Considering the variety of etiology 99–103. of thrombophilia, we should conduct a comprehensive examina- [5] Heit JA. Thrombophilia: common questions on laboratory assessment tion for determining its etiology. Cancer patient usually have and management. Hematol Am Soc Hematol Educ Program 2007; concurrent thrombophilia. Both clinical and laboratory findings 1:127–35. [6] Maduskuie TPJr, McNamara KJ, Ru Y, et al. Rational design and indicate that 90% of all metastatic cancers are accompanied by synthesis of novel, potent bis-phenylamidine carboxylate factor Xa abnormalities in coagulation variables, for example, circulating inhibitors. J Med Chem 1998;41:53–62. D-dimers, thrombin–antithrombin complexes, tissue factor (TF), [7] Cui L, Sun YH, Chen J, et al. Analysis of prethrombotic states in patients [6] [7] and other changes. Cui et al have shown that tumor cells with malignant tumors. Asian Pac J Cancer Prev 2015;16:5477–82. could impair the balance of coagulation, anticoagulant, and 2015/08/01. [8] Gon Y, Sakaguchi M, Takasugi J, et al. Plasma D-dimer levels and fibrinolytic system through multiple mechanisms, which leads to ischaemic lesions in multiple vascular regions can predict occult cancer in prethrombotic state. Therefore, cancer patients are vulnerable to patients with cryptogenic stroke. Eur J Neurol 2017;24:503–8. [3] stroke. However, Taccone et al retrospectively reviewed 5106 [9] Nam KW, Kim CK, Kim TJ, et al. Predictors of 30-day mortality and the ischemic stroke patients between 1991 and 2004, and identified risk of recurrent systemic thromboembolism in cancer patients suffering acute ischemic stroke. PLoS One 2017;12:e0172793. that a group of 24 patients (0.4%) had an underlying malignancy. [10] Lee AY. Anticoagulation in the treatment of established venous Furthermore, tumor cell early can spread via the lymphatic thromboembolism in patients with cancer. J Clin Oncol 2009;27: system without visible primary mass, which increases the 4895–901. difficulty of its diagnosis. Therein, the first-ever stroke revealing [11] Lyman GH, Bohlke K, Falanga A. Venous thromboembolism prophy- laxis and treatment in patients with cancer: American Society of Clinical an undiagnosed underlying malignancy is a very rare event. Also Oncology clinical practice guideline update. J Oncol Pract 2015;11: screening for lymph node metastases should not be ignored in e442–4. diagnosing cancer. A study indicates that higher D-dimer levels [12] Jang H, Lee JJ, Lee MJ, et al. Comparison of enoxaparin and warfarin for [8] can be a prediction of cancer-related stroke. In addition, Nam secondary prevention of cancer-associated stroke. J Oncol 2015; [9] et al reported that D-dimer levels may predict 30-day mortality 2015:502089. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Medicine Wolters Kluwer Health

Recurrent stroke in a patient of lung cancer without pulmonary mass

Download PDF
4 pages

Loading next page...
 
/lp/wolters_kluwer/recurrent-stroke-in-a-patient-of-lung-cancer-without-pulmonary-mass-2RP01xkzK7

References (14)

Publisher
Wolters Kluwer Health
Copyright
Copyright © 2018 the Author(s). Published by Wolters Kluwer Health, Inc.
ISSN
0025-7974
eISSN
1536-5964
DOI
10.1097/MD.0000000000009815
pmid
29384885
Publisher site
See Article on Publisher Site

Abstract

Rationale: Repeated occurring stroke in short intervals with hypercoagulability is unusual so in such cases the conventional vascular risk factors might not be the causes of stroke. Patient concerns: We have presented a case of 60-year-old male presenting with recurrent stroke due to thrombophilia. Diagnoses: Lung cancer was detected by superficial lymph nodes ultrasound and further pathological examination. Interventions: The patient suffered a recurrent stroke and he had persistently high level of D-dimer which suggested the diagnosis of thrombophilia, thus, he was treated with low-molecular-weight heparin. Unfortunately, the treatment was not effective for the patient and he died before any other treatments could be administered. Outcomes: Despite anticoagulant therapy, the patient suffered multiple episodes of stroke and ultimately died. Lessons: This case of recurrent stroke with coagulation disorders without evidence of cancer in imaging and blood test is rare. So in a stroke patient, we should consider malignancy or metastasis as a differential diagnosis as it may be the first manifestation of active cancer elsewhere. Abbreviations: ADC = apparent diffusion coefficient, CT = computed tomography, DWI = diffusion-weighted imaging, MRA, MRV = magnetic resonance angiography and venography, MRI = magnetic resonance imaging, PT-INR = prothrombin time- international normalized ratio, SWI = susceptibility-weighted imaging, TF = tissue factor. Keywords: lung cancer, radiological features, recurrent stroke, thrombophilia 1. Introduction infarction.Furthermore, theincidenceof cerebral infarction in lung [4] cancer is 1.43 times higher than it is in normal population. Stroke is the second most common cause of death and major cause However, as a primary manifestation in a tumor patient, stroke is [1] of disability worldwide. Referring to etiologies of stroke, over rare and is difficult to be identified in clinical practice, especially for [2] 150 potential causes have been listed. Apart from conventional those patients without visible mass. Here we report a rare case of vascular risk factors, cancer could play an important role in recurrentstroke with lungcancer withoutvisible solidmass in lung. patients’ vulnerability to stroke. Previous study has demonstrated that stroke in cancer patients is not rare during its clinical course, [3] presenting in up to 15% of patients. In addition, about 20% to 2. Case report 40% of cancer patients suffering from cerebral infarction lack A 60-year-old male was brought to the emergency department of [4] conventional stroke risk factors. Lung cancer is the most a local hospital for a sudden onset of vertigo, blurred vision, and common type of cancer, with the highest incidence of cerebral left-hand disability. A brain computed tomography (CT) scan was advised and admitted in the hospital. No abnormality was Editor: N/A. detected in the CT scan and the patient was diagnosed as acute cerebral infarction and treated with conventional cerebral The authors state that this study does not involve ethical committee approval, nor does it involve patient consent. vascular therapy. The symptoms had completely resolved with Funding: This study was funded by National Natural Science Foundation of China treatment so the patient was discharged from the hospital. (grant no. 81300940). However, these symptoms reoccurred twice after 7 days and 10 The authors have no conflicts of interest to disclose. days, respectively. On the 13th days, the symptoms reappeared Department of Neurology, Zhongnan Hospital of Wuhan University, Wuchang along with vision impairment and headache. Additionally, his District, Wuhan City, Hubei Province, People’s Republic of China. repeat brain CT scan showed bilateral cerebellum hemorrhagic Correspondence: Yan Xu, Department of Neurology, Zhongnan Hospital of infarction. The patient was then referred to our hospital. Our Wuhan University, No.169 Donghu Road, Wuchang District, Wuhan City, Hubei neurological evaluation revealed vague and dysmetria to the right Province, People’s Republic of China, 430071 (e-mail: shennei@outlook.com). side in finger-nose test. Diffusion-weighted imaging (DWI) and Copyright © 2018 the Author(s). Published by Wolters Kluwer Health, Inc. apparent diffusion coefficient (ADC) exhibited multiple acute This is an open access article distributed under the Creative Commons infarctions and a mixed signal in the left-occipital lobe. Attribution-NoDerivatives License 4.0, which allows for redistribution, commercial Susceptibility-weighted imaging (SWI) showed hemorrhagic and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author. infarcts in the left-occipital lobe and small hemorrhage lesions in bilateral corona radiata. MRI T2 FLAIR shows old lesions in Medicine (2018) 97:5(e9815) the right-frontal lobe and new lesions in bilateral occipital lobe Received: 29 November 2017 / Received in final form: 16 January 2018 / Accepted: 17 January 2018 and corona radiata. Whereas magnetic resonance angiography and venography (MRA, MRV) displayed no abnormality (Fig. 1). http://dx.doi.org/10.1097/MD.0000000000009815 1 Wang et al. Medicine (2018) 97:5 Medicine Figure 1. (A) MRI diffusion-weighted imaging sequence shows hyperintensity in the right cerebellum, bilateral hippocampus, occipital lobes, frontal and parietal lobes (thin arrow), a mixed signal in the left-occipital lobe (coarse arrow). (B) MRI T2/fluid-attenuated inversion recovery shows hypointensity in the right-frontal lobe (arrow). (C) MRI susceptibility-weighted imaging sequence shows hypointensity in the left-occipital lobe, bilateral frontal, and parietal lobes (arrow). (D) Magnetic resonance angiography (MRA) shows normal arteries. (E) Magnetic resonance venography (MRV) shows normal veins. MRA=magnetic resonance angiography, MRI=magnetic resonance imaging, MRV=magnetic resonance venography. In magnetic resonance imaging (MRI), new and old lesions occipital lobe. A repeated MRI showed increase in size of were seen in the involved cerebral portion along multiple vascular hemorrhagic infarction in the right-occipital lobe (Fig. 2). territories in both the anterior and posterior circulation. There Since, cardiac embolism is the most common cause for cerebral was no past history of common vascular risk factors and heart embolism, we performed echocardiography, holter monitor, and diseases, especially atrial fibrillation. Based on these findings, we foaming experiment to screen for underlying heart diseases considered emboli to be etiology of recurrent stroke. At the same (endocarditis, arrhythmia, particularly atrial fibrillation, and time, blood tests showed coagulation disorders with evaluated patent foramen ovale) which may induce the formation of prothrombin time-international normalized ratio (PT-INR) embolus but all these tests were normal. Vascular ultrasound was (1.45), evaluated D-dimer (2522 ng/mL), reduced antithrombin done to rule out deep vein thrombosis of lower extremities and (73%), and evaluated fibrin/fibrinogen degradation products thrombus was not found in lower extremity vessel. Therefore, we (45.75mg/mL), which suggested thrombophilia. The patient was supposed thrombophilia to be the reason of embolism while its given symptomatic treatment including mannitol dehydrate pathogenesis of was unclear. Due to mutilple etiology of therapy and removal of oxygen free radicals, and low- thrombophilia, likely systemic diseases such as connective tissue molecular-weight heparin was added for thrombophilia. Regard- disorder and cancer were taken into account. The laboratory less the treatment, the abnormal clotting and recurrent stroke workup for tumor markers, immune disorders, and infectious continued. The patient’s condition got worse and had paroxys- diseases were within normal limits. Additionally, there was no mal aggravating left-limbs disability. The left-limbs disability was family history of hypercoagulability, so thrombophilia due to partially relieved after half an hour. An emergency brain CT connective tissue diseases or inherited thrombophilia was un- performed showed suspicious hemorrhagic infarcts in bilateral likely. Cancers usually companies abnormalities in coagulation, Figure 2. (A) The brain CT scan shows suspicious hyperdense zones in bilateral occipital lobe. (B) Repeated MRI T2/fluid-attenuated inversion recovery shows an increasing mixed signal in the right-occipital lobe (arrow). CT=computed tomography, MRI=magnetic resonance imaging. 2 Wang et al. Medicine (2018) 97:5 www.md-journal.com Figure 3. (A) Superficial lymph nodes ultrasound shows swollen lymph nodes (arrow). Figure 5. Lymph node biopsy shows tumor cells are similar in size, the nucleus is round or oval, much of the nuclear chromatin is deeply stained (high magnification, hematoxylin, and eosin stain). so, although with normal tumor markers, further examination were carried out to rule out the diagnosis of malignancy. Bone marrow aspiration was done to screen for hematological cancer. that induced the recurrent stroke. The patient again had sudden Simultaneously, thoracic and abdominal CT scan, along with headache, nausea and vomiting and was agitated. His brain CT prostate ultrasound was also done. These test results were scan showed an extensive cerebral hemorrhage (Fig. 6). The normal. As evident, though a primary mass could not be located, patient died after 1 week. tumor cell may spread via the lymphatic system. So, superficial lymph nodes ultrasound performed revealed enlarged lymph 3. Discussion nodes in bilateral cervical, axillary, and inguinal region (Fig. 3A). Unfortunately, when the lymph node biopsy was planned, the We illustrated a case of recurrent stroke with thrombophilia patient had a new episode of stroke and he was completely caused by lung cancer, which was diagnosed by pathological blinded and his left limbs were paralyzed. Along with that he had examination, without any evidence in blood tests or chest CT frequent episodes of nausea and vomiting. The repeat enhanced scan. The brain MRI showed lesions involving multiple vascular MRI revealed new infarction in bilateral occipital lobe and territories in both the anterior and posterior circulation (bilateral parietal lobe and there was no obvious enhanced signal intensity middle cerebral artery and bilateral posterior cerebral artery, (Fig. 4). Once the patient was stable, lymph node biopsy was posterior inferior cerebellar artery) with co-existing new and old done and the result stated supraclavicular lymph node with lesions. Based on these points, we considered embolism to be the cause of recurrent stroke. Cardiac causes tumors and coagulation metastatic carcinoma. Immunohistochemistry results of tumor disorders because thrombophilia are common reasons of cell were: CD117 (), CD20 (), CDX2 (), CK7 (+), NapsinA embolism. Thrombophilia has an inherited or acquired predis- (+), OCT3/4 (), PLAP (), SALL4 (), TTF-1 (+), VILLIN (), position to thrombosis. Thrombophilia is not a disease itself, but a-inhibin (), Ki-67 (positive rate 60%), all of which suggested may be associated with other diseases (e.g., cancer), drug lung cancer (Fig. 5). In conclusion, it was the occult lung cancer Figure 4. The second repeated MRI diffusion-weighted imaging sequence shows hyperintensity in bilateral occipital lobe, frontal, and parietal lobes (arrow). MRI= magnetic resonance imaging 3 Wang et al. Medicine (2018) 97:5 Medicine in acute ischemic stroke patients with active cancer. For cancer patients with venous thromboembolism, treatment with low- molecular-weight heparin is the preferred agent based on the [10,11] [12] findings of large clinical trials. Similarly, Jang et al have reported that in patients with cancer-associated stroke, the D- dimer levels and the risk of recurrence decreased with enoxaparin administration. On the contrary, D-dimer levels and recurrent stroke were not prevented in spite of giving low-molecular-weight heparin in our case, which was unusual. Persistently high level of D-dimer indicates that the recurrent stroke may be related to tumor emboli and not the thrombus. As for ultimate extensive intracranial hemorrhage, which might be related to the metastatic tumors damaging vessel walls or abnormal clotting, the cause is unclear as autopsy was not done. 4. Conclusions Our case highlighted that recurrent stroke may be the first clinical manifestation for patients with metastatic tumor even without visible mass entity, particularly without conventional vascular risks factors. Tumor screening such as PET scan and lymph node examination are essential especially in the absence of solid tumor. References Figure 6. The repeated CT scan shows hyperdense zone in the right-medial temporal lobe. CT=computed tomography. [1] Donnan GA, Fisher M, Macleod M, et al. Stroke. Lancet 2008; 371:1612–23. [2] Dimitrovic A, Breitenfeld T, Supanc V, et al. Stroke caused by lung cancer invading the left atrium. J Stroke Cerebrovasc Dis 2016;25:e66–8. [3] Taccone FS, Jeangette SM, Blecic SA. First-ever stroke as initial exposure (e.g., oral contraceptives) or other conditions (e.g., presentation of systemic cancer. J Stroke Cerebrovasc Dis 2008;17: pregnancy or postpartum), and is known as acquired thrombo- 169–74. [4] Xie XR, Qin C, Chen L, et al. A clinical study on the pathogenesis of lung philia. Meanwhile, genetic defect in coagulation function may [5] cancer-related cerebral infarction. Zhonghua Nei Ke Za Zhi 2017;56: also cause thrombophilia. Considering the variety of etiology 99–103. of thrombophilia, we should conduct a comprehensive examina- [5] Heit JA. Thrombophilia: common questions on laboratory assessment tion for determining its etiology. Cancer patient usually have and management. Hematol Am Soc Hematol Educ Program 2007; concurrent thrombophilia. Both clinical and laboratory findings 1:127–35. [6] Maduskuie TPJr, McNamara KJ, Ru Y, et al. Rational design and indicate that 90% of all metastatic cancers are accompanied by synthesis of novel, potent bis-phenylamidine carboxylate factor Xa abnormalities in coagulation variables, for example, circulating inhibitors. J Med Chem 1998;41:53–62. D-dimers, thrombin–antithrombin complexes, tissue factor (TF), [7] Cui L, Sun YH, Chen J, et al. Analysis of prethrombotic states in patients [6] [7] and other changes. Cui et al have shown that tumor cells with malignant tumors. Asian Pac J Cancer Prev 2015;16:5477–82. could impair the balance of coagulation, anticoagulant, and 2015/08/01. [8] Gon Y, Sakaguchi M, Takasugi J, et al. Plasma D-dimer levels and fibrinolytic system through multiple mechanisms, which leads to ischaemic lesions in multiple vascular regions can predict occult cancer in prethrombotic state. Therefore, cancer patients are vulnerable to patients with cryptogenic stroke. Eur J Neurol 2017;24:503–8. [3] stroke. However, Taccone et al retrospectively reviewed 5106 [9] Nam KW, Kim CK, Kim TJ, et al. Predictors of 30-day mortality and the ischemic stroke patients between 1991 and 2004, and identified risk of recurrent systemic thromboembolism in cancer patients suffering acute ischemic stroke. PLoS One 2017;12:e0172793. that a group of 24 patients (0.4%) had an underlying malignancy. [10] Lee AY. Anticoagulation in the treatment of established venous Furthermore, tumor cell early can spread via the lymphatic thromboembolism in patients with cancer. J Clin Oncol 2009;27: system without visible primary mass, which increases the 4895–901. difficulty of its diagnosis. Therein, the first-ever stroke revealing [11] Lyman GH, Bohlke K, Falanga A. Venous thromboembolism prophy- laxis and treatment in patients with cancer: American Society of Clinical an undiagnosed underlying malignancy is a very rare event. Also Oncology clinical practice guideline update. J Oncol Pract 2015;11: screening for lymph node metastases should not be ignored in e442–4. diagnosing cancer. A study indicates that higher D-dimer levels [12] Jang H, Lee JJ, Lee MJ, et al. Comparison of enoxaparin and warfarin for [8] can be a prediction of cancer-related stroke. In addition, Nam secondary prevention of cancer-associated stroke. J Oncol 2015; [9] et al reported that D-dimer levels may predict 30-day mortality 2015:502089.

Journal

Medicine – Wolters Kluwer Health

Published: Feb 1, 2018

There are no references for this article.