Nonbacterial Thrombotic Endocarditis and Adenocarcinoma in Acute Stroke

Background and Rationale: Nonbacterial thrombotic endocarditis is a complication of mucin-producing adenocarcinoma. Aseptic valvular vegetations formed on valves are friable and frequently result in stroke. Immune mediated valvular endothelial damage and hypercoagulability have a role to play. Mucin, is also likely to increase the formation of intravascular thrombi. Treatment is difficult and requires use of anti-coagulant. Evidence of superiority of unfractionated heparin over low molecular wt heparin will be discussed. Methods: We conducted a retrospective review of the hospital stroke registry to identify patients diagnosed with embolic stroke secondary to Nonbacterial thrombotic endocarditis (NBTE). Individual patient records were then examined for patients demographics, imaging and confirmation of underlying malignancy. Results: Three patients were identified from the registry data for the period January to December 2015. All the patients were male and magnetic resonance imaging showed evidence of multiple ischemic infarcts across arterial territories, suggestive of an underlying embolic mechanism. All patients were confirmed to have disseminated malignancy and histopathology confirmed adenocarcinoma based on biopsies of isolated pulmonary lesions. In all patients, echocardiography (ECHO) and carotids ultrasound (CUS) showed no evidence of thrombi. Coagulation studies were normal. Conclusion: We describe three patients with NBTE and underlying adenocarcinoma. Blood investigations showed no evidence of hypercoagulability based on conventional assessments of coagulation. The diagnosis of ischemic stroke secondary to emboli was based on the MRI findings and despite normal ECHO, which is common in NBTE. Patients were treated with Low molecular weight heparin (LMWH) and suffered recurrent stroke. Unfortunately all three patients succumbed to their illness.