A Lernaean Hydra

Cancer is often accompanied by a hypercoagulable state, resulting in several thrombotic phenomena. Venous thromboembolism in the form of deep vein thrombosis or pulmonary embolism is the most common manifestation, but arterial thrombotic complications such as ischemic stroke also occur. On occasion, stroke might be the first clinical manifestation of malignancy and, in the absence of other explanations and in the appropriate clinical context, such as unexplained anemia or weight loss, a workup for systemic malignancy should be considered. Solid tumors, especially adenocarcinomas, are the most likely tumors to be linked with stroke. Besides the coagulation dysfunction, another potential source of embolism is nonbacterial thrombotic endocarditis, also known as marantic endocarditis, consisting of sterile vegetations in the heart valves. Systemic anticoagulation is recommended for stroke prevention, although the rate of recurrence is often high even with therapeutic anticoagulation doses. Cardiac surgery might be necessary in the case of marantic endocarditis.