title: Recurrent Stroke Due to Metastatic Pulmonary Tumor Emboli as an Important Clinical Entity.
abstract: We present an autopsy case of repetitive stroke due to tumor emboli, indistinguishable from thromboembolism with a hypercoagulable state in its clinical course. A 72-year-old man diagnosed with stage IVA oropharyngeal squamous cell carcinoma received chemoradiotherapy. Follow-up imaging revealed mediastinal lymph nodes and pulmonary metastasis. One year later, the patient experienced right arm weakness, and brain magnetic resonance imaging showed acute ischemic lesions in multiple vascular territories. He was diagnosed with paradoxical cerebral embolism due to cancer-associated venous thrombosis and treated with rivaroxaban. However, newly developed cerebral infarcts were confirmed 1 month later. Then, rivaroxaban treatment was switched to subcutaneous unfractionated heparin injection. He was admitted again for stroke recurrence and died of respiratory failure 8 days after admission. Autopsy demonstrated pulmonary metastasis invading the veins and tumor emboli in the culprit cerebral arteries. D-dimer was kept constant at a slightly higher level, ranging from 1 to 3 µg/mL during the course of recurrence. We should consider tumor embolism in the differential diagnosis of recurrent stroke along with pulmonary tumor and resistance to heparin preparations with unchanged D-dimer levels.
authors.affiliation: Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan. Electronic address: takasugi@neurol.med.osaka-u.ac.jp.
authors.forename: Junji
authors.initials: J
authors.lastname: Takasugi
authors.affiliation: Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Manabu
authors.initials: M
authors.lastname: Sakaguchi
authors.affiliation: Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Naoki
authors.initials: N
authors.lastname: Oyama
authors.affiliation: Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Yasufumi
authors.initials: Y
authors.lastname: Gon
authors.affiliation: Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Yasukazu
authors.initials: Y
authors.lastname: Terasaki
authors.affiliation: Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Tsutomu
authors.initials: T
authors.lastname: Sasaki
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Susumu
authors.initials: S
authors.lastname: Nakahara
authors.affiliation: Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Kenji
authors.initials: K
authors.lastname: Ohshima
authors.affiliation: Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Yumiko
authors.initials: Y
authors.lastname: Hori
authors.affiliation: Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Eiichi
authors.initials: E
authors.lastname: Morii
authors.affiliation: Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan. Electronic address: hmochizuki@neurol.med.osaka-u.ac.jp.
authors.forename: Hideki
authors.initials: H
authors.lastname: Mochizuki
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D001344:Autopsy; D015415:Biomarkers / Q000097:blood; D001706:Biopsy; D002294:Carcinoma, Squamous Cell / Q000150:complications / Q000000981:diagnostic imaging / Q000556:secondary* / Q000628:therapy; D038524:Diffusion Magnetic Resonance Imaging; D017809:Fatal Outcome; D005338:Fibrin Fibrinogen Degradation Products / Q000378:metabolism; D006258:Head and Neck Neoplasms / Q000150:complications / Q000473:pathology* / Q000628:therapy; D006801:Humans; D020766:Intracranial Embolism / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D008175:Lung Neoplasms / Q000150:complications / Q000556:secondary* / Q000628:therapy; D008207:Lymphatic Metastasis; D008297:Male; D009367:Neoplasm Staging; D009360:Neoplastic Cells, Circulating / Q000473:pathology*; D009959:Oropharyngeal Neoplasms / Q000150:complications / Q000473:pathology* / Q000628:therapy; D012008:Recurrence; D012131:Respiratory Insufficiency / Q000209:etiology; D000077195:Squamous Cell Carcinoma of Head and Neck; D020521:Stroke / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology*; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D015415:Biomarkers; D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D
keywords: Recurrent stroke; cancer-related stroke; pulmonary metastases; tumor embolism