Stroke in the setting of three-territory lesion pattern on magnetic resonance-diffusion-weighted imaging “three-territory sign” (TTS) is predominately due to cancer-associated hypercoagulation (CAH). Our goal is to determine the frequency with which “TTS” is overlooked as a diagnostic feature of cancer-associated hypercoagulation stroke.
Over a 4-year period (October 2016 to October 2020), stroke admissions with magnetic resonance imaging defined three-territory diffusion-weighted imaging lesions were identified. Patients were prospectively accrued in an observational study from the neurology service at Hartford Hospital, a 938 bed facility with a comprehensive stroke center with 2792 stroke admissions during the study period.
Twenty-two patients met selection criteria, 4 due to infectious endocarditis, 16 due to stroke from CAH and 2 with no identifiable etiology. Of the 16 CAH patients, 5 were male and 11 female, mean age=72 (range: 47 to 91). Cancer type (biopsy proven unless noted) was cholangiocarcinoma=3, adenocarcinoma of lung=3, adenocarcinoma of breast=1, pancreatic carcinoma=3 (2 biopsy, 1 ultrasound), adenocarcinoma, origin unknown=1, non−small cell carcinoma of lung=2, carcinoid=1, ovarian carcinoma=1, lung mass (not biopsied)=1. Malignancy was known in 7 and occult in 9 at stroke presentation. Consideration of malignancy-related hypercoagulation as the cause of stroke was appreciated in 1 of 16 radiology reports and in 4 of 16 neurology admission notes.
TTS is a frequently missed diagnostic magnetic resonance feature in cancer-associated hypercoagulation stroke and often heralds occult malignancy.