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.
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.
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 stroke11. 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/...
. The prothrombotic state of malignancy occurs due to the ability of tumor cells to activate the coagulation system22. 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/...
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References
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1Nouh 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 -
2Caine 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
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Publication in this collection
29 June 2020 -
Date of issue
July 2020
History
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Reviewed
13 Dec 2019 -
Received
08 Mar 2020 -
Accepted
19 Mar 2020