Pearls & Oy-sters: Large vessel ischemic stroke secondary to glioblastoma multiforme

Abstract

Large vessel ischemic strokes uncommonly account for new focal deficits in patients with primary brain tumors, mimicking intratumoral hemorrhage, tumor progression, or Todd paralysis. Stroke occurring in the context of a primary brain tumor is usually a postoperative complication, a late complication of radiation therapy, or embolic due to a hypercoagulable state induced by the tumor. Rarely, direct vessel occlusion by an adjacent primary brain tumor may cause a large vessel ischemic stroke. CASE REPORT A 41-year-old right-handed nonsmoker with glioblastoma multiforme and no known vascular risk factors developed sudden onset right upper extremity weakness 7 months after he was diagnosed with left temporal glioblastoma multiforme by stereotactic biopsy, 5 months after treatment with radiation therapy and temozolomide, and 4 months after gross total resection with placement of Gliadel wafers. His past medical history was negative for hypertension, hyperlipidemia, diabetes, or coronary artery disease. On examination, he was unable to lift his right arm against gravity. MRI revealed a left corona radiata infarct. Gadolinium-enhanced T1 images revealed complete occlusion of the left middle cerebral artery (MCA) at M1 (figure, A). No secondary stroke prevention therapy was initiated. Two months later, he presented with transcortical motor aphasia due to an acute extension of his previous stroke, as evidenced by new diffusionweighted imaging findings. Magnetic resonance angiography (MRA) showed an occluded left MCA, with some indistinct distal filling from collaterals (figure, B). A workup included 48-hour telemetry which revealed no arrhythmias, and a transthoracic echocardiography which revealed no clots, and no patent foramen ovale. He was not started on aspirin because of temozolomide-related thrombocytopenia.