Acute Ischemic Stroke as a Manifestation of Pancreatic Adenocarcinoma

Abstract

Objectives: Pancreatic adenocarcinoma (PDAC) is an aggressive malignancy often diagnosed at an advanced stage due to nonspecific symptoms. While venous thromboembolism (VTE) is a well-recognized complication, ischemic stroke as the initial manifestation of pancreatic cancer is rare. Stroke in malignancy can result from hypercoagulability, nonbacterial thrombotic endocarditis (NBTE), or paradoxical embolism via a patent foramen ovale (PFO). Recognizing these mechanisms is critical for timely diagnosis and intervention. Methodology: A 62-year-old female with no significant past medical history presented with acute-onset word-finding difficulty. Her symptoms began five days prior with watery diarrhea and abdominal cramps, followed by progressive fatigue. On the day of admission, she developed expressive aphasia, prompting evaluation. MRI confirmed an acute ischemic stroke. A transthoracic echocardiogram revealed a large patent foramen ovale (PFO), and Doppler ultrasound detected a deep vein thrombosis (DVT), raising concern for paradoxical embolism as the stroke mechanism. During hospitalization, the patient reported abdominal pain, leading to further imaging. A CT scan revealed a pancreatic mass with liver metastases, later confirmed on MRI. She underwent an endoscopic ultrasound-guided biopsy of the pancreatic lesion which showed pancreatic adenocarcinoma. She was referred to an oncologist for further management. Conclusion: This case highlights the association between pancreatic cancer and hypercoagulability, manifesting as paradoxical embolism in the setting of an undiagnosed malignancy. Stroke may be the initial presentation of an underlying malignancy, emphasizing the need for a thorough evaluation of thromboembolic events, particularly in patients with PFO and VTE.