Topography of ischemic strokes in cancer-associated non-bacterial thrombotic endocarditis: A single-institution descriptive case series

Very limited data indicate that patients with stroke from cancer-associated NBTE (Ca-NBTE) exhibit a characteristic pattern of widely distributed ischemic lesions of varying sizes. An electronic search of Mayo Clinic records (03/31/2002-06/30/2022) with ensuing manual review of brain magnetic resonance imaging (MRI) was performed to identify topographic characteristics of stroke from Ca-NBTE. In 112 patients with Ca-NBTE, 92 (82.1 %) had a stroke and 84 (76.5 %) had an MRI available for analysis (mean age 62.7±9.2, 57 women). 64 (76.2 %) patients had ischemic strokes in both cerebral hemispheres, 10 (11.9 %) had isolated left hemispheric infarcts, and 7 (8.3 %) had isolated right hemispheric infarcts. Strokes involving both the anterior and posterior circulation were seen in 66 (78.6 %) patients. Disseminated small, medium, and large ischemic strokes (Type IV) were seen in 57 (67.8 %), multiple punctate disseminated strokes (Type III) in 14 (16.7 %), multiple strokes in a single vascular territory (Type II) in 7 (8.3 %), and a single ischemic stroke (Type I) in 6 (7.1 %) patients. Strokes were most commonly observed in the middle cerebral artery territories – on the right in 65 (77.4 %) and on the left in 68 (81.0 %) patients. Strokes within the right posterior cerebral artery territory were observed in 54 (64.3 %) and the left posterior cerebral artery territory in 54 (64.3 %) patients. 46 (54.8 %) patients had strokes in the right cerebellum and 50 (59.5 %) had strokes in the left cerebellum. Only 5 patients had strokes in the right brainstem and 3 in the left brainstem. Ca-NBTE is most commonly associated with multifocal bihemispheric ischemic strokes of varying sizes involving both the anterior and posterior circulation, but solitary infarcts or infarcts confined to a single vascular territory can also be seen.