: Ipsilateral weakness following a right CVA in a patient with metastatic pancreatic cancer: A case report

Case Diagnosis: 59-year-old-male with pancreatic cancer and significant metastases to the liver

Case Description or Program Description: This patient initially presented to the hospital with right upper extremity weakness which started six hours prior to arrival. He had a history of recurrent DVTs and failed on apixaban. He was switched to enoxaparin and warfarin, which he remained on until this event. On physical exam the patient’s only presenting symptom was right upper extremity weakness. CT scan of the head demonstrated an acute infarct involving the right frontal and occipital lobe. CTA revealed significant narrowing of one M2 branch. This is inconsistent with the patient’s physical exam which should show left-sided weakness. The initial theory was that the patient had brain metastases affecting the left frontal lobe. However, MRI only showed this same stroke as well as old micro-infarcts involving bilateral occipital, right parietal, and left frontal lobe. This patient was admitted to acute rehabilitation with lingering upper extremity weakness. Four weeks following the initial stroke the patient presented with new onset memory and personality changes. Physical exam demonstrated no other focal neurological findings. CT revealed a new infarction along the inferior left temporal lobe along with a new lacunar infarction within the right cerebellum.

Setting: Acute rehabilitation center

Assessment/Results: Clinical course: The patient eventually became reoriented. No new neurological deficits beside memory changes. Per patient and family request a palliative care meeting was set up to discuss prognosis. Ultimately, the decision was made to transition to comfort care.

Discussion (relevance): Ipsilateral weakness following a stroke is a rare phenomenon, with theories including functional reorganization of the brain to compensate for previous injury.

Conclusions: This case highlights a rare instance of ipsilateral weakness following a stroke. It also demonstrates the increased risk of CVA in patients with advanced cancer, despite intensive medical therapy and the challenges it can pose in rehabilitation.