Figure 3.

Hidden cancer and stroke caused by cancer-related coagulopathy. A 49-year-old woman presented with recurrent left arm weakness and sensory changes. Vascular study and transthoracic echocardiogram were negative. Microembolic signals were detected during transcranial Doppler monitoring. TCD shunt test showed right-to-left shunt and leg duplex revealed occlusion of right leg veins. Serum D-dimer level was elevated to 6.23 μg/mL (normal <0.5 μg/mL) and CA-125 level was 489.6 U/mL (normal range up to 35 U/mL). Abdominopelvic magnetic resonance image (MRI) showed a 6 cm right ovarian cancer and a 2.2 cm endometrial cancer, both at stage 1a with no metastasis. D-dimer level was lower after anticoagulation with enoxaparin. The patient experienced recurrent stroke with elevation of D-dimer levels during the period of discontinuation for tumor resection. After surgery, anticoagulation therapy was restarted and she remained stable without stroke recurrence. Anticoagulation therapy was discontinued after 6 months of surgery, and D-dimer levels remained in the normal range. DWI, diffusion-weighed image; LMWH, low-molecular weight heparin; TCD MES, transcranial duplex microembolic signal.