Objective:

The goal of this case report is to educate neurologists on a unique stroke presentation in an immunocompromised patient.

Background:

Malignancy has been shown to increase risk of ischemic stroke. About 50% of cancer-related strokes have cryptogenic etiology, however they are hypothesized to typically be related to thromboembolic events and hypercoagulability of malignancy. New diagnosis of solid tumors is associated with increased risk of hypercoagulability. However, hematologic malignancy such as chronic lymphocytic leukemia (CLL) is not typically associated with hypercoagulability. Cancer in general can increase stroke risk in other ways, including intracranial radiation, heightened systemic inflammation and atherosclerosis, and even increased psychological stress. In patients with hematologic malignancy who have a stroke, further investigation into etiology is often warranted, including infectious evaluation due to possible immunocompromised status.

Design/Methods:

N/A

Results:

Case description: We present a case of a A 77 year old male with active CLL, on acalabrutinib, admitted for neutropenic fever, who developed acute-onset right-sided hemiparesis five days into his hospital stay. Imaging was consistent with a left pontine infarct, initially believed to be small vessel etiology from hypertension. Subsequent fluctuation of symptoms resulted in further imaging demonstrating worsening infarct, to eventually a full pontine infarct. Review of serial imaging showed progressive sinus infection causing erosion of patient’s skull base and subsequent irritation of pontine arteries, causing a small vessel injury and resultant infarct.

Conclusions:

Discussion: This case demonstrates a unique stroke etiology in an immunocompromised patient. It reveals the importance of comparing serial imaging, broadening differentials in stroke workup, and having a thorough infectious evaluation for immunocompromised patients.