Suhaniya Samarasinghe
Chelsea and Westminster Hospital, UK
Title: Therapeutic challenges in occult malignancy presenting as stroke
Biography
Biography: Suhaniya Samarasinghe
Abstract
Ischaemic stroke is a rare first presentation of occult malignancy. Malignancy related hypercoagulability can manifest as acute arterial infarction, non-bacterial thrombotic endocarditis and/or thrombophlebitis. We report three cases of acute ischaemic stroke all presenting within a four-month period. The first patient presented with multiple acute cerebral infarcts. Following an episode of acute hypoxia, the patient had CT pulmonary angiography - this confirmed the presence of multiple bilateral pulmonary emboli. Further imaging showed evidence of metastatic ovarian cancer and renal infarction. The second patient presented with dense left-sided weakness and MRI confirmed right middle cerebral artery (MCA) infarct. CT scan performed for deranged blood tests confirmed bilateral pulmonary emboli, likely hepatic metastases, renal and splenic infarcts and gastrointestinal outflow tract obstruction. Both patients showed progression of their hypercoagulability state despite therapeutic low molecular weight heparin (LMWH) monotherapy. LMWH is the current preferred choice of anticoagulation for venous thromboembolism (VTE) in oncology patients. The third patient presented with an acute stroke on a background of non-rheumatic atrial fibrillation - which is an independent risk factor for stroke. She was on a direct Factor Xa inhibitor on presentation. The patient had a CT scan for an abdominal mass – this showed metastatic pancreatic malignancy. Currently, no studies have specifically addressed the treatment of malignancy related VTE using direct inhibitors.
Conclusion: Possible occult malignancy should be considered in patients with on-going hypercoagulability state despite appropriate anticoagulation. Currently, there is limited data for this patient subgroup and further studies examining anticoagulant choice is needed.
Recent Publication:
Gokce M, Benli E M, Dinc A (2012) Arterial Ischemic Stroke as a First Manifestation of Trousseau’s Syndrome. International Journal of Clinical Medicine 3, 43-45.