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Ischaemic stroke is a rare first presentation of occult malignancy. Malignancy related hypercoagulability can manifest as acute arterial
infarction, non-bacterial thrombotic endocarditis and/or thrombophlebitis. We report three cases of acute ischaemic stroke all
presenting within a four-month period. The first patient presented with multiple acute cerebral infarcts. Following an episode of acute
hypoxia, the patient had CT pulmonary angiography - this confirmed the presence of multiple bilateral pulmonary emboli. Further
imaging showed evidence of metastatic ovarian cancer and renal infarction. The second patient presented with dense left-sided
weakness and MRI confirmed right middle cerebral artery (MCA) infarct. CT scan performed for deranged blood tests confirmed
bilateral pulmonary emboli, likely hepatic metastases, renal and splenic infarcts and gastrointestinal outflow tract obstruction. Both
patients showed progression of their hypercoagulability state despite therapeutic low molecular weight heparin (LMWH) monotherapy.
LMWH is the current preferred choice of anticoagulation for venous thromboembolism (VTE) in oncology patients. The
third patient presented with an acute stroke on a background of non-rheumatic atrial fibrillation - which is an independent risk factor
for stroke. She was on a direct Factor Xa inhibitor on presentation. The patient had a CT scan for an abdominal mass – this showed
metastatic pancreatic malignancy. Currently, no studies have specifically addressed the treatment of malignancy related VTE using
Conclusion: Possible occult malignancy should be considered in patients with on-going hypercoagulability state despite appropriate
anticoagulation. Currently, there is limited data for this patient subgroup and further studies examining anticoagulant choice is
Suhaniya Samarasinghe received her medical degree from the University of Southampton. She started her postgraduate medical training in the Northern Deanery becoming a member of the Royal College of Physicians, London in 2015. Dr. Samarasinghe began her higher specialist training in Geriatrics and General Internal Medicine as part of the North West London rotation where she worked for two years. It was during this time that she developed an interest in acute and hyper acute stroke.
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