ISCHEMIC STROKE IN A PATIENT WITH SUSPECTED CERVICAL CANCER: A THERAPEUTIC DILEMMA BETWEEN ANTICOAGULANT OR ANTIPLATELET STRATEGIES IN A RESOURCE-LIMITED SETTING: A RARE CASE REPORT
DOI:
https://doi.org/10.20961/magnaneurologica.v4i2.3062Keywords:
anticoagulant, antiplatelet, antithrombotic, cervical cancer, hypercoagulability, ischemic strokeAbstract
Background: Approximately 5% of strokes with no identifiable cause are linked to previously undiagnosed malignancies. The involvement of multiple vascular territories observed on brain imaging may indicate a hypercoagulable state related to cancer. Early identification is crucial for prompt cancer diagnosis.
Case: A 40-year-old woman with no established classic stroke risk factors presented with progressive left-sided weakness and difficulty with speech over three days. She had a history of persistent vaginal bleeding lasting four months. Non-contrast brain CT revealed multiple infarcts affecting the right frontoparietal region, left frontal lobe, and bilateral posterior as well as left anterior internal capsules. An abdominal ultrasound identified a 9.35 × 4.74 cm hypoechoic mass extending from the cervix to the uterus with bladder infiltration, findings highly suggestive of cervical carcinoma.
Discussion: Ischemic stroke associated with female reproductive malignancies is rare, with an incidence of around 0.3%. It is mainly caused by cancer-related hypercoagulability due to tumor-derived mucin, procoagulants, and inflammatory cytokines. Multifocal infarcts across various vascular territories may indicate a hypercoagulable state and suggest an underlying malignancy. There is no standardized anticoagulant protocol. Low-molecular-weight heparin (LMWH) is commonly used, though its effectiveness varies. Use of direct oral anticoagulants (DOACs) and antiplatelets is increasing, showing similar safety and efficacy.
Conclusion: To date, there is no definitive antithrombotic of choice for cancer-associated ischemic stroke. The selection of antithrombotic therapy should be carefully tailored based on individual risk factors and the patient's clinical condition.
References
1. Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, et al. An Updated Definition of Stroke for the 21st Century: A Statement for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke; 2013. 44(7):2064-89. DOI: 10.1161/STR.0b013e318296aeca
2. Feigin VL, Brainin M, Norrving B, Martins SO, Pandian J, Lindsay P, et al. World Stroke Organization: Global Stroke Fact Sheet 2025. Int J Stroke; 2025. 20(2):132-44. DOI: 10.1177/17474930241308142
3. Capirossi C, Laiso A, Renieri L, Capasso F, Limbucci N. Epidemiology, Organization, Diagnosis and Treatment of Acute Ischemic Stroke. Eur J Radiol Open; 2023. 11:100527. DOI: 10.1016/j.ejro.2023.100527
4. Ntaios G, Perlepe K, Lambrou D, Sirimarco G, Strambo D, Eskandari A, et al. Prevalence and Overlap of Potential Embolic Sources in Patients With Embolic Stroke of Undetermined Source. J Am Heart Assoc; 2019. 8(15). DOI: 10.1161/JAHA.119.012858
5. Verhoeven JI, Fan B, Broeders MJM, Driessen CML, Vaartjes ICH, Klijn CJM, et al. Association of Stroke at Young Age with New Cancer in the Years after Stroke among Patients in the Netherlands. JAMA Netw Open; 2023. 6(3). DOI: 10.1001/jamanetworkopen.2023.5002
6. Sandio A. Prevalence and Management of Stroke in Resource-Limited Settings: A Retrospective Study. J Cardiovasc Cardiol; 2025. 1-6. DOI: 10.61440/JCC.2025.v3.50
7. Boehme AK, Esenwa C, Elkind MSV. Stroke risk factors, genetics, and prevention. Circ Res; 2017. 120(3):472-95. DOI: 10.1161/CIRCRESAHA.116.308398
8. Akhwazain S, Candrakanti B, Safitri R, Aqila Y, Azami K, Subadiyasa IMA. (Evidence Based Case Report) Stroke risk prognosis in type 2 diabetes mellitus patients with hypertension. Indones J Med Educ (Inomed); 2025. 5(2). DOI: 10.33860/inomed.v5i2.31755.
9. Navi BB, Iadecola C. Ischemic Stroke in Cancer Patients: A Review of an Underappreciated Pathology. Ann Neurol; 2018. 83(5):873-83. DOI: 10.1002/ana.25227
10. Tsai SJ, Huang YS, Tung CH, Lee CC, Lee MS, Chiou WY, et al. Increased Risk of Ischemic Stroke in Cervical Cancer Patients: A Nationwide Population-Based Study. Radiat Oncol; 2013. 8(1). DOI: 10.1186/1748-717X-8-41
11. Dardiotis E, Aloizou AM, Markoula S, Siokas V, Tsarouhas K, Tzanakakis G, et al. Cancer-Associated Stroke: Pathophysiology, Detection and Management. Int J Oncol; 2019. 54(3):779-96. DOI: 10.3892/ijo.2019.4669
12. Campia U, Moslehi JJ, Amiri-Kordestani L, Barac A, Beckman JA, Chism DD, et al. Cardio-Oncology: Vascular and Metabolic Perspectives: A Scientific Statement From the American Heart Association. Circulation; 2019. 139(13):E579-E602. DOI: 10.1161/CIR.0000000000000641
13. Navi BB, Kasner SE, Elkind MSV, Cushman M, Bang OY, DeAngelis LM. Cancer and Embolic Stroke of Undetermined Source. Stroke; 2021. 52(3):1121-1130. DOI: 10.1161/STROKEAHA.120.032002
14. Drobni ZD, Alvi RM, Taron J, Zafar A, Murphy SP, Rambarat PK, et al. Association Between Immune Checkpoint Inhibitors With Cardiovascular Events and Atherosclerotic Plaque. Circulation; 2020. 142(24):2299-2311. DOI: 10.1161/CIRCULATIONAHA.120.049981
15. Huang R, Zhou Y, Hu S, Ren G, Cui F, Zhou PK. Radiotherapy Exposure in Cancer Patients and Subsequent Risk of Stroke: A Systematic Review and Meta-Analysis. Front Neurol; 2019. 10:233. DOI: 10.3389/fneur.2019.00233
16. Navi BB, Kasner SE, Cushman M, Okwuosa TM, Fleming NH, Behr JM, et al. Classification and Management of Ischemic Stroke in Patients With Active Cancer: A Scientific Statement From the American Heart Association. Stroke; 2026. 57(4). DOI: 10.1161/STR.0000000000000517
17. Steinauer F, Bücke P, Buffle E, et al. Prevalence of Right-to-Left Shunt in Stroke Patients With Cancer. Int J Stroke; 2024. 19(9):1020-1027. DOI: 10.1177/17474930241260589
18. Lee EJ, Nah HW, Kwon JY, Kang DW, Kwon SU, Kim JS. Ischemic Stroke in Patients with Cancer: Is It Different from Usual Strokes? Int J Stroke; 2014. 9(4):406-12. DOI: 10.1111/ijs.12124
19. Chi X, Zhao R, Pei H, Xing A, Hu S, Chen J, et al. Diffusion-Weighted Imaging-Documented Bilateral Small Embolic Stroke Involving Multiple Vascular Territories May Indicate Occult Cancer: A Retrospective Case Series and a Brief Review of the Literature. Aging Med (Milton); 2020. 3(1):53-9. DOI: 10.1002/agm2.12105
20. Gupta S, Gupta N, Singhal S, Nair N. Carcinoma Cervix Presenting as Ischemic Stroke in Young Female: A Case Report and Review of Literature. J Clin Diagn Res; 2017. 11(4):QD01-QD02. DOI: 10.7860/JCDR/2017/21065.9639
21. Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke; 2021. 52(7):E364-E467. DOI: 10.1161/STR.0000000000000375
22. Raskob GE, van Es N, Verhamme P, Carrier M, di Nisio M, Garcia D, et al. Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. N Engl J Med; 2018. 378(7):615-24. DOI: 10.1056/NEJMoa1711948
23. Lee MJ, Chung JW, Ahn MJ, Kim S, Seok JM, Jang HM, et al. Hypercoagulability and Mortality of Patients with Stroke and Active Cancer: The OASIS-CANCER Study. J Stroke; 2017. 19(1):77-87. DOI: 10.5853/jos.2016.00570
24. Nam KW, Kim CK, Kim TJ, An SJ, Oh K, Ko SB, et al. Treatment of Cryptogenic Stroke with Active Cancer with a New Oral Anticoagulant. J Stroke Cerebrovasc Dis; 2017. 26(12):2976-80. DOI: 10.1016/j.jstrokecerebrovasdis.2017.07.029
25. Navi BB, Zhang C, Miller B, Cushman M, Kasner SE, Elkind MSV, et al. Apixaban vs Aspirin in Patients with Cancer and Cryptogenic Stroke: A Post Hoc Analysis of the ARCADIA Randomized Clinical Trial. JAMA Neurol; 2024. 81(9):958-65. DOI: 10.1001/jamaneurol.2024.2404
26. Navi BB, Marshall RS, Bobrow D, Singer S, Stone JB, DeAngelis LM, et al. Enoxaparin vs Aspirin in Patients With Cancer and Ischemic Stroke: The TEACH Pilot Randomized Clinical Trial. JAMA Neurol; 2018. 75(3):379-381. DOI: 10.1001/jamaneurol.2017.4211
27. Beavers CJ, Rodgers JE, Bagnola AJ, Beckie TM, Campia U, Di Palo KE, et al. Cardio-Oncology Drug Interactions: A Scientific Statement From the American Heart Association. Circulation; 2022. 145(15):E811-E838. DOI: 10.1161/CIR.0000000000001056
28. Xu Y, Cole K, Collins E, Moledina A, Mallity C, Carrier M. Anticoagulation for the Prevention of Arterial Thrombosis in Ambulatory Cancer Patients: Systematic Review and Meta-Analysis. JACC CardioOncol; 2023. 5(4):520-532. DOI: 10.1016/j.jaccao.2023.04.003
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Yang Yang Endro Arjuna, Vonny Fibrianty Goenawan, Vivien Puspitasari, Yohanes Chandra Kurniawan
This work is licensed under a Creative Commons Attribution 4.0 International License.
This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/).
