Large vessel occlusion at the intersection of malignancy, infective endocarditis, and disseminated intravascular coagulation in a young patient: A fatal course despite successful thrombectomy

Introduction: In systemic malignancy, cerebrovascular events can arise from hypercoagulability, endocarditis, and tumor embolism. We present a young patient who developed a left middle cerebral artery (MCA) M1 thrombus in the setting of malignancy, infective endocarditis, and disseminated intravascular coagulation (DIC).Case: A thirty-six-year-old woman was found on diffusion-weighted magnetic resonance imaging, obtained for blurred vision, to have bilateral cerebral and cerebellar acute ischemic foci, and low-molecular-weight heparin (LMWH; 2×4,000 IU) was started. While on treatment, she presented with inability to speak and right-sided weakness noticed after waking up. Motor aphasia, flattening of the right nasolabial sulcus, and 2/5 strength in the right extremities were found; the National Institutes of Health Stroke Scale (NIHSS) score was 10–11. Computed tomography angiography showed a thrombus in the left MCA M1 segment with preserved distal flow, and cranial imaging showed bilateral temporal metastatic lesions. Intravenous thrombolysis was not given because the onset time was unknown and there was an intracranial metastasis; mechanical thrombectomy was performed. Complete recanalization [Thrombolysis in Cerebral Infarction (TICI) 3] was achieved, and the NIHSS fell to 4–5. 18F-fluorodeoxyglucose positron emission tomography/computed tomography showed intense uptake in a 3.5 cm spiculated primary lesion in the right lung [maximum standardized uptake value (SUVmax): 13.12] and in the temporal metastases. During follow-up, the platelet count fell to 24,000/µL, bleeding developed, and the International Society on Thrombosis and Haemostasis DIC score was 7. LMWH was discontinued and fondaparinux was started; plasma, cryoprecipitate, and platelet replacement were given. Transthoracic echocardiography showed a mobile vegetation on the aortic valve. Streptococcus pyogenes and Staphylococcus hominis grew in blood cultures. Dry gangrene of all four extremities and occlusion of the right superficial femoral artery developed. A lymph node biopsy showed metastatic carcinoma, and a bone marrow biopsy was consistent with hemophagocytosis. The patient, who developed acute respiratory distress syndrome/pneumonia, anuric renal failure, focal seizures, and subarachnoid hemorrhage, died after cardiac arrest on day 20 (Figure 1 and 2).Discussion/Conclusion: Although mechanical thrombectomy achieved successful recanalization and early neurological improvement, infective endocarditis, DIC, and septic complications accompanying malignancy can progress to fatal hemostatic collapse and multiple organ failure. A multidisciplinary approach and close management of the bleeding-thrombosis balance are important.Keywords: