Multiple Thrombectomies in the Same Patient within One Month: Case Report of a Patient with Trousseau Syndrome and Acute Ischemic Stroke

Abstract

Background and Importance: Since Trousseau’s initial publication, the development of thromboembolic events related to malignancy has been well established. The pathophysiology of this is understood to be through activation of the coagulation cascade through neoplastic cells themselves or the therapy initiated (chemotherapy or surgery). To date, there have been a variety of studies, such as the OASIS-CANCER trial, which highlight the relationship of hypercoagulability to ischemic stroke. Despite these efforts, clear evidence is lacking for the utilization of antiplatelet or anticoagulation therapy in the secondary prevention of stroke following mechanical thrombectomy in patients with suspected or confirmed malignancy. Clinical Presentation: A 71-year-old female with a history of immune thrombocytopenia, diabetes mellitus, and hypertension who was undergoing an evaluation for a lung nodule, later determined to be adenocarcinoma of the lung, underwent three successful mechanical thrombectomies for acute ischemic stroke with large vessel occlusion over a one month period. This patient had improved National Institutes of Health Stroke Scale (NIHSS) scores following each of her thrombectomies. However, her history of immune thrombocytopenia and underlying malignancy complicated her discharge medication regimen following each of her thrombectomies and may have contributed to her repeat strokes. Conclusion: Clear guidance is lacking regarding the utilization of antiplatelet and anticoagulation therapy in patients with suspected or confirmed malignancy following mechanical thrombectomy. Review of the literature suggests that controlling a patient’s hypercoagulability may lead to improved clinical outcomes, but further clinical trials are warranted.

Multiple Thrombectomies for Cerebral and Coronary Artery Occlusion in Trousseau Syndrome

“…13,14) In these studies, risk factors of re-occlusion included the number of device passes, missed residual thrombus or stenosis on the past angiography after thrombectomy, intracranial ICA or M2 occlusion, stroke of undetermined cause, and statin pretreatment. 13,14) According to our research, there are 14 reported incidences of TS treated by MT with available literature [2][3][4]13,[15][16][17][18][19][20][21][22] (Table 1). Of half of the cases that experienced re-occlusion of the cerebral large vessels, five cases involved the same vessels.…”

“… 22) Cicilioni et al proposed the presence of circulating extracellular vesicles, which is associated with the activation of neutrophil extracellular traps and thrombus formation in the presence of an underlying malignancy. 19) Only two of these five cases described required retreatment. One case underwent contact aspiration (CA) again, while the other was performed stenting.…”

“…Despite continuous infusion being an ideal method to maintain stable drug concentrations, 4) it is unsuitable for long-term administration. Therefore, when we changed to subcutaneous injection, it required careful and strict management of heparinization by monitoring the activated partial thromboplastin time and D-dimer 19) to prevent thrombosis. Clinicians should recognize the risk of ischemic events and determine to what degree anticoagulation therapy is needed in TS patients.…”

Factors related to white thrombi in acute ischemic stroke in cancer patients

“…There is a possibility of large vessel reocclusion relatively early after thrombectomy due to cancer-related stroke. [30][31][32] Large vessel reocclusion may contribute to poor outcome after thrombectomy due to cancer-related stroke.…”

A case report of Trousseau syndrome

“…Studies have confirmed that LMWH is the preferred treatment and prevention method for cancer-related thromboembolic events, and oral anticoagulant drugs have been shown to be ineffective. [4] In the OASIS-CANCER trial, suggested that successful correction of hypercoagulability based on D-dimer values was associated with improved survival and reduced recurrence. [5] This relies mainly on LMWH.…”