title: Trousseau's Syndrome, a Previously Unrecognized Condition in Acute Ischemic Stroke Associated With Myocardial Injury.
abstract: Trousseau's syndrome is a well-known malignancy associated hypercoagulative state leading to venous or arterial thrombosis. The pathophysiology is however poorly understood, although multiple mechanisms are believed to be involved. We report a case of Trousseau's syndrome resulting in concomitant cerebral and myocardial microthrombosis, presenting with acute ischemic stroke and markedly elevated plasma troponin T levels suggesting myocardial injury. Without any previous medical history, the patient developed multiple cerebral infarctions and died within 11 days of admission. The patient was postmortem diagnosed with an advanced metastatic adenocarcinoma of the prostate with disseminated cerebral, pulmonary, and myocardial microthrombosis. Further analyses revealed, to the best of our knowledge for the first time in stroke patients, circulating microvesicles positive for the epithelial tumor marker CK18 and citrullinated histone H3 in thrombi, markers of the recently described cancer-associated procoagulant DNA-based neutrophil extracellular traps. We also found tissue factor, the main in vivo initiator of coagulation, both in thrombi and in metastases. Troponin elevation in acute ischemic stroke is common and has repeatedly been associated with an increased risk of mortality. The underlying pathophysiology is however not fully clarified, although a number of possible explanations have been proposed. We now suggest that unexplainable high levels of troponin in acute ischemic stroke deserve special attention in terms of possible occult malignancy.
authors.affiliation: Karolinska Institutet, Dept of Clinical Sciences, Division of Internal Medicine, Danderyd Hospital, Stockholm, Sweden.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Thalin
authors.affiliation: Karolinska Institutet, Dept of Clinical Sciences, Division of Pathology, Danderyd Hospital, Stockholm, Sweden.
authors.forename: Bo
authors.initials: B
authors.lastname: Blomgren
authors.affiliation: Karolinska Institutet, Dept of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Stockholm, Sweden.
authors.forename: Fariborz
authors.initials: F
authors.lastname: Mobarrez
authors.affiliation: Karolinska Institutet, Dept of Clinical Sciences, Division of Internal Medicine, Danderyd Hospital, Stockholm, Sweden.
authors.forename: Annika
authors.initials: A
authors.lastname: Lundstrom
authors.affiliation: Karolinska Institutet, Dept of Clinical Sciences, Division of Internal Medicine, Danderyd Hospital, Stockholm, Sweden.
authors.forename: Ann Charlotte
authors.initials: AC
authors.lastname: Laska
authors.affiliation: Karolinska Institutet, Dept of Clinical Sciences, Division of Internal Medicine, Danderyd Hospital, Stockholm, Sweden.
authors.forename: Magnus
authors.initials: M
authors.lastname: von Arbin
authors.affiliation: Karolinska Institutet, Dept of Clinical Sciences, Division of Radiology, Danderyd Hospital, Stockholm, Sweden.
authors.forename: Anders
authors.initials: A
authors.lastname: von Heijne
authors.affiliation: Karolinska Institutet, Dept of Clinical Sciences, Division of Internal Medicine, Danderyd Hospital, Stockholm, Sweden.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Rooth
authors.affiliation: Karolinska Institutet, Dept of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Stockholm, Sweden.
authors.forename: Hakan
authors.initials: H
authors.lastname: Wallen
authors.affiliation: Karolinska Institutet, Dept of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Stockholm, Sweden.
authors.forename: Sara
authors.initials: S
authors.lastname: Aspberg
keywords: Trousseau; malignancy; myocardial infarction; stroke; thrombosis; troponin