Introduction - as cancer patients survive longer more present with strokes caused by hypercoagulability, vascular involvement, non-infective endocarditis and side effects of chemotherapy. Clinical features and lack of conventional risk factors should alert physicians to the significance of cancer or to search for occult malignancy. We present cases illustrating these increasingly common challenges
Method - we analysed all ischaemic strokes admitted July 2015 to June 2017 for diagnosis of cancer, cryptogenic strokes or multiple territory infarcts
Results - of 1105 ischaemic strokes, mean age 78, 114 (10%) had a concurrent diagnosis of cancer, 7 multiple. They included breast 25, intestinal tract 24, gynaecological 9, prostate 33, lung 9. There were examples of infarcts affecting multiple vascular territories (Embolic Stroke of Uncerain Source, ESUS). Infarcts proliferated despite anticoagulation eg. in an 81y old woman with breast cancer and pulmonary embolus and a 61y old woman with ovarian cancer on bevacizumab.
In some patients stroke led to the diagnosis of cancer, as in a 66y old woman with frontal and cerebellar infarcts and raised D-dimer (lung adenocarcinoma) and a 51y old woman with a subclavian vein thrombosis, pulmonary embolism and occipital and scattered infarcts (colon cancer). Other mechanisms for stroke were non-infective endocarditis, radiotherapy or block dissection leading to late carotid occlusion (two cases), and thrombogenic chemotherapeutic regimes.
Conclusion - Consider cancer as acauise for stroke in patients with ESUS, particularly multiple territory infarcts, anticipate resistance to usual anti-thrombotic treatments and search for new occult malignancy in such patients, raised D-dimer  being a useful prompt

THE CHALLENGE OF MANAGING STROKE IN THE SETTING OF CANCER AND THE IMPORTANCE OF SEARCHING FOR OCCULT MALIGNANCY IN CASES OF ESUS