Trousseau Syndrome with the MR Three-territory Sign as the Initial Manifestation of an Occult Pancoast Tumor: A Case Report
Hadeer Elsaeed AboElfarh1, Dena Elghzzawy1, Mohamed Abokhalil1, Basma Elged2, Ayat Elbasyouni Enani Elbasyouni 2, Ibrahim Elmenshawi1
1Neurology Department, Faculty of Medicine, Mansoura University, 2Diagnostic & Interventional Radiology Department, Faculty of Medicine, Mansoura University
Objective:
To present this interesting case of a young female patient who presented with the MR three-territory sign and was found to have an occult Pancoast tumor.
Background:
Pancoast tumors are rare tumors, representing 3% to 5% of bronchogenic carcinomas, located in the apex of the lung. Trousseau syndrome refers to cancer-associated arteriovenous thromboembolism. There are few cases reporting trousseau syndrome with cerebral infarction as the initial manifestation of occult tumors. Cerebral infarctions involving three vascular territories on MR diffusion-weighted imaging (DWI) are called “three-territory sign” (TTS). In the absence of an embolic source, this sign is almost always due to stroke related to cancer-associated hypercoagulation (CAH).
Design/Methods:
Case Report
Results:
A 35-year-old female patient was admitted to our neurology department at Mansoura University Hospitals due to two attacks of right-side hemiparesis and hemihypoesthesia associated with right upper motor neuron facial involvement, four months apart. The first attack regressed completely after vascular treatment. In the second attack, she presented with global aphasia and one attack of right focal to bilateral motor tonic colonic seizure. The condition was preceded by unexplained DVT affecting both lower limbs sequentially six months before the admission. She wasn’t on contraceptive pills. When MR-DWI was done, multiple restricted diffusion lesions involving bilateral anterior and posterior circulations were found. Echocardiography was normal. She underwent pan-CT, which revealed a suspicious mass in the apex of the right lung (Pancoast tumor) with hilar lymphadenopathy. She underwent CT-guided fine needle aspiration, and core needle biopsy which revealed undifferentiated malignant tumor. Unfortunately, she died shortly after the biopsy.
Conclusions:
TTS is a highly specific marker that is frequently found in malignancy-related ischemic stroke, yet it’s still an overlooked diagnostic feature. Hence, once TTS is found, a Transesophageal Echocardiogram should be done to exclude cardioembolic causes, as well as a pan-CT to confirm or exclude occult malignancy.