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CC BY-NC-ND 4.0 · Arq Neuropsiquiatr 2020; 78(07): 453
DOI: 10.1590/0004-282X20200035
Images in Neurology

Three territory sign in cancer-related acute ischemic stroke

Sinal de três territórios arteriais em acidente vascular cerebral isquêmico agudo relacionado a câncer
Marcelo Houat DE BRITO 
1   Hospital Sírio-Libanês, São Paulo SP, Brazil.
2   Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
3   Instituto do Câncer do Estado de São Paulo, São Paulo SP, Brazil.
,
Gabriela Almeida PIMENTEL 
1   Hospital Sírio-Libanês, São Paulo SP, Brazil.
2   Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil.
,
Marcos Fernando de Lima DOCEMA 
1   Hospital Sírio-Libanês, São Paulo SP, Brazil.
,
Mateus Correa da TRINDADE 
1   Hospital Sírio-Libanês, São Paulo SP, Brazil.
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A 64-year-old man, on regular use of apixaban due to atrial fibrillation (AF), was admitted to the hospital with sudden right upper limb weakness. Brain MRI ([Figure 1]) demonstrated a Three Territory Sign (TTS, bilateral anterior and posterior circulation acute ischemic diffusion-weighted imaging lesions). Complimentary etiologic investigation diagnosed an adenocarcinoma of the ascending colon by full-body 18F-FDG PET/CT ([Figure 2]), followed by a local biopsy.

Zoom Image
Figure 1 Brain MRI diffusion-weighted image - DWI (Row A) showing multiple high signal intensity lesions in the cerebral and cerebellar hemispheres involving three different vascular territories (Three Territory Sign), with apparent diffusion coefficient - ADC (Row B), showing the same lesions with low signal intensity.
Zoom Image
Figure 2 FDG-PET/CT showing hypermetabolic alterations compatible with cecum/ascending colon tumor (arrows) extending to adjacent adipose planes.

TTS is a highly specific marker and six times more frequently observed in malignancy-related than AF-related ischemic stroke[1]. The prothrombotic state of malignancy occurs due to the ability of tumor cells to activate the coagulation system[2].



Publikationsverlauf

Eingereicht: 08. März 2020

Angenommen: 19. März 2020

Artikel online veröffentlicht:
13. Juni 2023

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  • References

  • 1 Nouh AM, Staff I, Finelli PF. Three Territory Sign: An MRI marker of malignancy-related ischemic stroke (Trousseau syndrome). Neurol Clin Pract. 2019 Apr;9(2):124-8. https://doi.org/10.1212/CPJ.20200035202000350603
  • 2 Caine GJ, Stonelake PS, Lip GY, Kehoe ST. The hypercoagulable state of malignancy: pathogenesis and current debate. Neoplasia. 2002 Nov-Dec;4(6):465-73. https://doi.org/10.1038/sj.neo.7900263