A Case of Intrahepatic Cholangiocarcinoma Developing Stroke Despite Direct Oral Anticoagulant Therapy

Abstract

A 73-year-old female presented with jaundice. Computed tomography revealed a hepatic mass and enlarged lymph nodes. Endoscopic ultrasound-guided tissue acquisition confirmed intrahepatic cholangiocarcinoma with lymph node metastasis. Upon admission, elevated D-dimer levels prompted a lower limb venous ultrasound, which identified central deep vein thrombosis (DVT) in the left leg. Direct oral anticoagulant (DOAC) therapy was initiated. Following biliary stent placement and improvement of jaundice, chemotherapy with GEM, CDDP, and Durvalumab was commenced. Initial brain MRI screening showed no stroke, but on the 14th day of hospitalization, the patient developed consciousness disturbance and was diagnosed with a new stroke due to left middle cerebral artery occlusion. Thrombectomy was performed, and heparin infusion therapy was administered. The patient's consciousness improved, and after rehabilitation, chemotherapy was resumed on the 78th day. Cancer-associated thrombosis is the second leading cause of death in cancer patients and a significant complication. Despite DOAC therapy for DVT, this case of intrahepatic cholangiocarcinoma developed a stroke. While the efficacy of DOAC in cancer-associated venous thromboembolism has been demonstrated, their effectiveness in cancer-associated stroke remains inconclusive and warrants careful consideration.