Advanced gynecologic malignancy identified after acute stroke case report

Abstract

Background Endometrial carcinosarcomas are rare and carry a very poor prognosis. They usually present with extensive lymphatic spread. An acute presentation of a stroke may reveal the underlying diagnosis. Case presentation A woman in her 50s with no reported medical history presented to the emergency department as a code stroke. She was found during the evening by her sister leaving the bathroom disheveled. At that time, she was found to be mute, not following commands, with left gaze deviation and right hemiparesis. Computed tomography (CT) imaging showed an acute infarct in the left middle cerebral artery M2 branch or frontoparietal territory consistent with acute stroke. Upon further review, the sister states that she has had significant vaginal bleeding and never had menopause. On admission, she had significant anemia. CT of the abdomen and pelvis showed a large right adnexal mass, endometrial thickening, diffuse lymphadenopathy, omental nodularity, and a pulmonary nodule concerning for gynecologic malignancy with metastasis. Surgical pathology showed high grade endometrial carcinosarcoma. She was outside of the tPA window, and neurology determined her not to be a candidate for thrombectomy. She was managed medically with antiplatelet agents, high dose atorvastatin, and blood transfusions. Conclusions Endometrial carcinosarcoma can present with severe anemia and irregular menstrual bleeding. In patients without routine gynecologic care, endometrial carcinosarcoma can go unnoticed and only be identified after workup for another condition such as acute stroke. Endometrial biopsy for diagnosis may be challenging in a patient with severe anemia. Alternatively, transvaginal ultrasonography with Doppler study and magnetic resonance imaging may be used to support the diagnosis. Furthermore, endometrial carcinosarcoma can complicate ischemic stroke management as it can present with bleeding and make it difficult to use anticoagulating agents.