History
Mrs. Lui was a 70-year-old lady with a history of locally invasive adenocarcinoma of the uterus and adenocarcinoma of the left breast. Given the advanced malignancy and poor functional status, symptomatic care has been decided.
She was initially admitted for fever and has been hospitalized for 2 months. Microbiological workup has been unrevealing. There was an episode of paroxysmal atrial fibrillation during the period of sepsis.
She developed acute onset altered mental state with incoherent speech. A plain CT of the brain revealed a hypodensity at the right anterior limb of the internal capsule.
A plain CT of the brain was repeated one week after the initial scan because of the persistent altered consciousness. The serial scan was remarkable for new hypodensities over both cerebral hemispheres. The neurology team was consulted for the abnormal CT brain, focusing on the probability of brain metastases.
No meaningful history could be elicited from the patient.
Physical examination
Physical examination demonstrated a disoriented patient with generalized weakness, which was asymmetrically worse on the left.
Investigations
A review of the CT scan showed multiple hypodensities in the bilateral cerebral hemispheres across several vascular territories, most of which were wedge-shaped, with grey white involvement, and a predilection for the cortical/subcortical regions. There was no significant perilesional edema or mass effect.
Though process
The pathology was localized to the cerebrum given the altered higher function and asymmetrical weakness. This was in concordance with the greater lesion burden over the right cerebral hemisphere.
The CT brain findings were suggestive of infarcts based on the descriptions above, and could be typical of an embolic shower. Cerebral metastases do have a predilection for the grey white junction, yet the clinical scenario was less compatible.
The etiology of embolic stroke could be ascribed to paroxysmal atrial fibrillation. However, given the presence of red flags, including background advanced malignancy and sepsis of uncertain source, further considerations should be applied to the differentials of hypercoagulability state secondary to malignancy, non-bacterial thrombotic endocarditis, infective endocarditis, and vasculitis.
Next steps
A contrast MRI brain with angiogram was arranged to clarify the nature of the lesions. An echocardiogram was arranged to look for valvular lesions and intracardiac thrombus. The risk of anticoagulation was deemed to outweigh the benefits provided the known bleeding tendency.