Case Report: Trousseau syndrome presenting as multifocal cerebral infarctions in advanced gastric signet-ring cell carcinoma: tumor burden-driven hypercoagulability.

BACKGROUND

Malignancy-associated hypercoagulability is a well-recognized driver of thromboembolic events in patients with advanced cancer. Arterial complications, including ischemic stroke, can develop despite appropriate anticoagulation and are often accompanied by markedly elevated D-dimer levels, reflecting sustained coagulation activation in the setting of advanced malignancy.

CASE PRESENTATION: A 76-year-old man presented with gastrointestinal bleeding and was subsequently diagnosed with advanced gastric signet-ring cell carcinoma with extensive hepatic and retroperitoneal metastases. During hospitalization, he developed acute left-sided hemiplegia. Brain magnetic resonance imaging revealed multiple acute infarctions involving both cerebral hemispheres and the cerebellum across distinct vascular territories, consistent with a systemic embolic pattern. The D-dimer level increased to approximately 23.7 μg/mL at the time of neurological deterioration. After gastrointestinal bleeding had stabilized, anticoagulation with enoxaparin sodium 4,000 anti-Xa IU subcutaneously twice daily was initiated; however, D-dimer remained elevated at approximately 23.1 μg/mL on May 21. Following initiation of systemic chemotherapy with the XELOX regimen, neurological deficits improved, accompanied by a decline in D-dimer from approximately 17.5 μg/mL before chemotherapy to approximately 14.9 μg/mL on June 2.

CONCLUSION

This case underscores the characteristic radiological features of malignancy-associated stroke and highlights the close relationship between tumor burden and systemic hypercoagulability. The observed temporal association between chemotherapy initiation and reduction in D-dimer levels supports the concept that effective tumor-directed therapy, in addition to anticoagulation, may be necessary to mitigate cancer-related thrombotic complications. Early multidisciplinary intervention is essential to optimize both neurological recovery and oncologic management.