ArticleFrontiers in cardiovascular medicine2026
Trousseau syndrome presenting with recurrent multi-territory infarctions: a case report of two patients highlighting divergent outcomes and dynamic hypercoagulability under direct oral anticoagulants and low-molecular-weight heparin.
Article in Frontiers in cardiovascular medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Trousseau syndrome is a cancer-associated hypercoagulable state characterized by recurrent thromboembolic events, including ischemic stroke. Optimal anticoagulation strategies remain controversial, particularly regarding the effectiveness of direct oral anticoagulants (DOACs) compared with low-molecular-weight heparin (LMWH). Case presentation: We report two patients with Trousseau syndrome who presented with recurrent multi-territory cerebral infarctions despite ongoing DOAC therapy. Case 1 was a 66-year-old man with active intrahepatic cholangiocarcinoma who developed repeated ischemic strokes and deep vein thrombosis while receiving rivaroxaban. After switching to LMWH, D-dimer levels decreased markedly. However, anticoagulation was de-escalated in the context of apparent normalization of D-dimer, followed by recurrent stroke, subsequent discontinuation of anticoagulation, and a rapid surge in D-dimer levels, ultimately resulting in death. Case 2 was a 74-year-old man with suspected recurrent metastatic gastric adenocarcinoma who developed ischemic stroke while on rivaroxaban. Following transition to LMWH, D-dimer levels progressively declined, and the patient remained clinically stable without recurrence during follow-up. A longitudinal timeline analysis integrating biomarker dynamics, treatment transitions, and clinical events demonstrated distinct patterns between the two cases, suggesting a potential discordance between D-dimer levels and underlying hypercoagulable activity. Conclusion: These cases highlight the dynamic nature of hypercoagulability in Trousseau syndrome. Normalization of D-dimer alone may not reliably indicate sustained control of malignancy-associated hypercoagulability and should not be used in isolation to guide anticoagulation de-escalation. LMWH may provide more consistent control in selected high-risk patients, although causal inference cannot be established from this report.
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