Een ischemische beroerte als presentatie van een occulte maligniteit: typisch beeld op een MRI van de hersenen

Abstract

Stroke as the first manifestation of an occult malignancy: typical pattern on a diffusion-weighted MRI An 89-year-old woman was admitted to the emergency department with temporary loss of coordination in her right arm. Diffusion-weighted imaging revealed the ‘three territory sign’ (TTS): multiple high-signal intensities in the territories of both the anterior and posterior circulations. Although a cardioembolic source is often suggested as the cause of multiple ischemic lesions, TTS is frequently seen in patients with a concomitant malignancy. When further investigated, the patient was diagnosed with a pancreatic carcinoma. The ischemic stroke was considered the first manifestation of the carcinoma, as conventional causes were excluded. Patients with a malignancy have an increased risk of an ischemic stroke. A potential explanation for this phenomenon is cancer-associated hypercoagulability. The treatment of cancer-associated hypercoagulability remains a challenge for clinicians. By analogy with the therapy for venous thromboembolic disorders in cancer patients, low-molecular-weight heparins (LMWH) could also be used safely and effectively for cancer-associated ischemic stroke. In different studies, variable results are observed with direct oral anticoagulants (DOACs) in the treatment of cancer-associated ischemic stroke. Despite the strong theoretical considerations, no clear benefit has been demonstrated for the use of anticoagulant versus antiplatelet therapy in this population. Further prospective research is needed.