Three territory sign in cancer-related acute ischemic stroke

A 64-year-old man, on regular use of apixaban due to atrial fibrillation (AF), was admitted to the hospital with sudden right upper limb weakness. Brain MRI ([Figure 1]) demonstrated a Three Territory Sign (TTS, bilateral anterior and posterior circulation acute ischemic diffusion-weighted imaging lesions). Complimentary etiologic investigation diagnosed an adenocarcinoma of the ascending colon by full-body 18F-FDG PET/CT ([Figure 2]), followed by a local biopsy.

Figure 1 Brain MRI diffusion-weighted image - DWI (Row A) showing multiple high signal intensity lesions in the cerebral and cerebellar hemispheres involving three different vascular territories (Three Territory Sign), with apparent diffusion coefficient - ADC (Row B), showing the same lesions with low signal intensity.

Figure 2 FDG-PET/CT showing hypermetabolic alterations compatible with cecum/ascending colon tumor (arrows) extending to adjacent adipose planes.

TTS is a highly specific marker and six times more frequently observed in malignancy-related than AF-related ischemic stroke[1]. The prothrombotic state of malignancy occurs due to the ability of tumor cells to activate the coagulation system[2].

Conflict of interest:

There is no conflict of interest to declare.

• References

• 1 Nouh AM, Staff I, Finelli PF. Three Territory Sign: An MRI marker of malignancy-related ischemic stroke (Trousseau syndrome). Neurol Clin Pract. 2019 Apr;9(2):124-8. https://doi.org/10.1212/CPJ.20200035202000350603
• 2 Caine GJ, Stonelake PS, Lip GY, Kehoe ST. The hypercoagulable state of malignancy: pathogenesis and current debate. Neoplasia. 2002 Nov-Dec;4(6):465-73. https://doi.org/10.1038/sj.neo.7900263

Publication History

Received: 08 March 2020

Accepted: 19 March 2020

Article published online:
13 June 2023