Triple Thrombectomy for Trousseau Syndrome: Case Report and Review of the Literature of Stroke Intervention in Cancer-associated Thrombus

Catherine Wassef, Audrey Grenga, Bruce Goldman, Thomas Mattingly
2020 Journal of Neuroendovascular Therapy  
Objective: There are few papers regarding repeat mechanical thrombectomy or thrombectomy for Trousseau's related stroke. We present a unique case of repeat thrombectomy due to Trousseau's syndrome affecting the same vessel in a patient with metastatic cancer. Case Presentation: A 47-year-old male presented with a full left middle cerebral artery syndrome and a National Institute of Health Stroke Scale of 17, despite regular apixaban use. He underwent mechanical thrombectomy successfully but
more » ... uccessfully but developed recurrent symptoms on postoperative day (POD) 6 while on warfarin. He underwent two additional thrombectomies, the final one requiring glycoprotein IIa/IIIb inhibitor for emergent implantation of intracranial stent. Successful recanalization (thrombolysis in cerebral infarction 2b) was achieved, and the patient was discharged home on dual antiplatelet therapy and enoxaparin on POD 10 after last thrombectomy, ambulatory and independent in his activities of daily living. The patient expired as a result of his metastatic disease 109 days after the third procedure and was ambulatory for 91 of those days. Conclusion: This case illustrates the palliative aspects of mechanical thrombectomy and the complexities of anticoagulation management in patients with the metastatic disease Trousseau's syndrome. Keywords▶ cancer, stroke, Trousseau, repeat thrombectomy, anticoagulation (about 6%). 1) However, a more recent literature indicates an increased risk of stroke, especially recurrent stroke, in cancer patients over the general population. 2) There are multiple etiologies for stroke in cancer patients, including shared comorbidities (age and smoking), direct tumor embolus, radiation-induced large vessel disease, inflammation, and paradoxical emboli secondary to venous thrombi. There are a few case reports of mechanical thrombectomy for cancer-related stroke, and of these, only one involved repeat thrombectomy >24 hours from initial embolectomy and none involved three embolectomies in the same vessel. [3] [4] [5] [6] We present an unusual case of repeated thrombosis, and subsequent thrombectomy, of the same intracranial territory. Our aggressive approach of triple thrombectomy for this patient resulted in preservation of his ability to communicate and ambulate until he ultimately passed due to his underlying cancer. We believe that mechanical thrombectomy, although aggressive, is an appropriate palliative procedure in select patients with end-stage metastatic disease. Nuances of anticoagulation management unique to this oncology cohort are illustrated by this case.
doi:10.5797/jnet.cr.2019-0111 fatcat:344lpfnm2bfadntihhxphwre2u