Stroke patients with cancer-associated hypercoagulability often present multiple areas of cortical infarction and a higher level of D-dimer. These patients often suffer from adenocarcinoma of the lung, prostate and colorectal, etc. Hepatocellular carcinoma (HCC) is often associated with bleeding diathesis. Although HCC secretes tissue factors proceeding the coagulation process, ischemic stroke is rarely found. 
    
    Serum D-dimer, a degraded products of fibrinolysis as an indicator of hypercoaguability, is associated with mortality, neurologic prognosis, and recurrence of systemic thromboembolism in these patients. Anticoagulants could attenuate hypercoaguablity and decrease the amount of D-dimer. In cancer-associated deep vein thrombosis, low molecular heparin is the first-line suggestion, but that is not convenient and has lower medical adherence to the patient. Vitamin K antagonist, warfarin, can be considered but does not interrupt the coagulant cascade directly. Warfarin may do not be helpful to attenuate hypercoagulable status but increase the risk of bleeding.  Theoretically, direct oral anticoagulants (DOAC) can block factor X or factor II directly. These drugs could stop coagulation cascades accelerated by tissue factor and factor X-like molecules secreted from the cancer cells. However, the treatment of cancer-associated stroke is still controversial currently. 

    Herein, we report a particular case with hepatocellular carcinoma presenting with acute multiple embolic stroke with a high level of D-dimer. He received DOAC with stroke prevention. D-dimer decreased during the application of DOAC. Unfortunately, D-dimer elevated and recurrent stroke recurred after the discontinuation of DOAC. This case suggest the necessity, efficacy of DOAC for cancer patient with hypercoaguability associated stroke.

Unusual clinical manifestations of stroke in a patient with hepatocellular carcinoma: Clinical experience and review of the literature