Three territory sign in cancer-related acute ischemic stroke

Sinal de três territórios arteriais em acidente vascular cerebral isquêmico agudo relacionado a câncer

A 64-year-old man, on regular use of apixaban due to atrial fibrillation (AF), was admitted to the hospital with sudden right upper limb weakness. Brain MRI (Figure 1) demonstrated a Three Territory Sign (TTS, bilateral anterior and posterior circulation acute ischemic diffusion-weighted imaging lesions). Complimentary etiologic investigation diagnosed an adenocarcinoma of the ascending colon by full-body 18F-FDG PET/CT (Figure 2), followed by a local biopsy.

Figure 1.
Brain MRI diffusion-weighted image - DWI (Row A) showing multiple high signal intensity lesions in the cerebral and cerebellar hemispheres involving three different vascular territories (Three Territory Sign), with apparent diffusion coefficient - ADC (Row B), showing the same lesions with low signal intensity.

Figure 2.
FDG-PET/CT showing hypermetabolic alterations compatible with cecum/ascending colon tumor (arrows) extending to adjacent adipose planes.

TTS is a highly specific marker and six times more frequently observed in malignancy-related than AF-related ischemic stroke¹. The prothrombotic state of malignancy occurs due to the ability of tumor cells to activate the coagulation system².

References

• ¹
  Nouh AM, Staff I, Finelli PF. Three Territory Sign: An MRI marker of malignancy-related ischemic stroke (Trousseau syndrome). Neurol Clin Pract. 2019 Apr;9(2):124-8. https://doi.org/10.1212/CPJ.0000000000000603
  » https://doi.org/https://doi.org/10.1212/CPJ.0000000000000603
• ²
  Caine GJ, Stonelake PS, Lip GY, Kehoe ST. The hypercoagulable state of malignancy: pathogenesis and current debate. Neoplasia. 2002 Nov-Dec;4(6):465-73. https://doi.org/10.1038/sj.neo.7900263
  » https://doi.org/https://doi.org/10.1038/sj.neo.7900263

Publication Dates

• Publication in this collection
  29 June 2020
• Date of issue
  July 2020

History

• Reviewed
  13 Dec 2019
• Received
  08 Mar 2020
• Accepted
  19 Mar 2020