Mahmoud Hsairi, Yahya el Harras, Achraf Saidi, Kaoutar Imrani, Ittimade Nassar
Journal: Medpeer Publisher
ISSN: 3066-2737
Volume: 3
Issue: 10
Date of Publication: 2026/10/31
Cerebrovascular complications are a recognized cause of morbidity in the oncological population. However, an acute ischemic stroke can occasionally serve as the primary clinical manifestation of a previously concealed malignancy. Trousseau syndrome, broadly defined as a cancer-associated hypercoagulable state, frequently precipitates catastrophic thromboembolic events, including ischemic strokes across multiple distinct vascular territories.
We report the case of a 60-year-old patient admitted to the emergency department for diffuse abdominal pain. An abdominal computed tomography CT scan revealed multiple suspicious hepatic lesions without peritoneal carcinomatosis. An ultrasound-guided liver biopsy was subsequently performed. Histopathological examination demonstrated infiltration of the hepatic parenchyma by malignant gland- forming epithelial cells, consistent with a moderately differentiated adenocarcinoma. During the clinical course, the patient developed a deep vein thrombosis and acute altered mental status accompanied by severe agitation. While the agitation precluded a cholangiopancreatography MRI to locate the primary tumor, an urgent brain magnetic resonance imaging was successfully performed. Diffusion-weighted imaging and Apparent Diffusion Coefficient mapping objectified multiple, widely disseminated acute ischemic foci involving both the anterior and posterior compartments. Initial evaluation revealed no major cardioembolic source, atrial fibrillation, or significant extracranial arterial stenosis. Recognition of the "Three-Territory Sign" may serve as an important clue suggesting an underlying cancer-associated hypercoagulable state and may prompt further investigation for occult malignancy. A diagnosis of Trousseau syndrome secondary to an adenocarcinoma of unknown primary was consequently established.
This case highlights the importance of considering cancer-associated hypercoagulability in patients presenting with unprovoked, multi-territorial acute ischemic strokes. Recognition of the "Three-Territory Sign" on diffusion-weighted MRI may provide a valuable clue to an otherwise occult malignancy and should prompt further evaluation for an underlying cancer-associated hypercoagulable state.
brain mri, cancer-associated ischemic stroke, occult adenocarcinoma, three-territory sign, trousseau syndrome
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