Paraneoplastic Prothrombotic State Causing Recurrent Ischemic Stroke ; a case report

Abstract

Abstract Background This case report is a good example of when to suspect a paraneoplastic prothrombotic state (PPS) as a cause of ischemic stroke (IS). Many clinical, laboratory and imaging features linked to PPS are well illustrated in this patient. Case presentation A 78 years old patient, known for a single 2x1,5cm middle lobe lung nodule who was on apixaban 5mg BID for documented pulmonary embolisms in his latest hospitalization, was admitted to the stroke unit for left-sided hemianopia and hemineglect. Brain MRI showed multifocal acute and subacute infarcts involving the anterior and posterior cerebral arteries and the right cerebellum. The standard stroke work-up were unremarkable beside a mild normocytic anemia (122 g/L) and a high d-dimers level. The patient returned to the hospital, eleven days after discharge for new left MCA infarcts confirmed by head CT. At this point, D-dimers were still very high (>4,400 ng/ml), C-reactive protein was slightly increased (14 mg/L) and there was still a mild inflammatory anemia. Cancer work-up was started and confirmed a stage III lung adenocarcinoma. Conclusion In this stroke patient, an etiological diagnosis of PPS was supported by the presence of a lung nodule, negative standard neurovascular workup, stroke recurrence (despite anticoagulation), infarcts in multiple vascular territories, and markers of systemic inflammation (anemia, high CRP) and active fibrinolysis (high d-dimers). This etiology should be considered in IS patients presenting with those PPS markers.