Paraneoplastic Stroke: Primary Occlusion and Early Reocclusion of the M2 Segment of the Middle Cerebral Artery Treated with Repeated Single-Pass Thrombectomy

We present the case of a 54-year-old woman with a past medical history of metastatic lung adenocarcinoma treated with a tyrosine kinase inhibitor and rivaroxaban. Although she was reportedly well 7 h prior to this event, she was admitted to the hospital after awakening with signs and symptoms of a left hemisphere stroke with an initial National Institutes of Health Stroke Score (NIHSS) of 6. While the results of a noncontrast head computed tomography (CT) were unremarkable, CT angiography (CTA) and CT perfusion (CTP) studies revealed an occlusion of the M2 segment of the left middle cerebral artery (MCA; inferior division) and a hypoperfused zone in the region of the cerebral cortex supplied by a left posterior branch of the MCA, respectively. The patient underwent a successful and uneventful endovascular revascularization of the left MCA occlusion. Significant neurological improvement was observed immediately after extubation, with a postprocedure NIHSS of 2. Twelve hours later, she abruptly developed global aphasia, right-sided weakness, and right hemianopia; her NIHSS declined to 14. An urgent cranial CT study revealed hypodensity in the left insula and the region lateral to the insular ribbon of the cerebral cortex supplied by the MCA together with evidence of petechial hemorrhagic transformation. CTA revealed reocclusion of the inferior division of the left MCA within the proximal M2 segment. The patient underwent a second endovascular revascularization procedure to recanalize the left MCA occlusion. Her NIHSS after extubation was 10. A follow-up noncontrast CT revealed an ischemic area in the region supplied by the left MCA with minor hemorrhagic transformation and an Alberta Stroke Program Early CT Score (ASPECTS) of 5 points. Anticoagulation with enoxaparin was initiated 24 h after the procedure, and the patient was discharged after 10 days with an NIHSS of 9 and a modified Rankin Scale (mRS) score of 3. We consider this case together with a discussion of the incidence and characteristics of cancer-related stroke.