Abstract Details

Cholangiocarcinoma is the second most common primary hepatic malignancy, with an estimated incidence of 2.5 per 100,000 and nearly 20% of deaths from hepatobiliary cancer. The development of arterial thromboembolism (particularly ischemic stroke) has been associated with 4-5-fold increased mortality in this population, accounting for 31% of all recurrent thromboembolic incidents. We present a case series of cholangiocarcinoma patients presenting with extensive acute ischemic strokes despite being on DOAC.

Identify the role of direct-acting oral anticoagulants (DOAC) as secondary prevention for ischemic strokes in bile duct cancer (cholangiocarcinoma). Recurrent thromboembolism, predominantly arterial, should warrant screening for bile duct malignancy, cholangiocarcinoma. 

Case series and review of literature.

Case 1: 54-year-old woman with unresectable cholangiocarcinoma (elevated CEA) and bilateral lower extremity deep venous thrombosis (DVT) diagnosed recently (on full dose Apixaban) presents with right frontal and insular ischemic strokes who underwent thrombectomy for right M1 and M2 occlusion. Patient was discharged to rehab and switched to Dabigatran.

Case 2: 68-year-old woman with hypertension, extensive coronary artery disease (myocardial infarctions x4), atrial fibrillation (previously on Warfarin then full dose Apixaban), lower extremity DVT requiring endovascular thrombectomy presents with right basal ganglia, insular, temporoparietal, and occipital ischemic infarctions. An echocardiogram showed left atrial thrombus. Heparin drip was started and later switched to therapeutic Enoxaparin. CT chest/abdomen/pelvis showed cholangiocarcinoma with elevated CA19-9 levels. Patient passed away after 10 weeks.

Recurrent ischemic strokes while on anticoagulation should prompt cancer screening and hypercoagulable states testing, particularly cholangiocarcinoma, as an expedited early diagnosis might lead to a 5-year survival rate of 25% if no metastasis. There is scarce data that clearly define the efficacy and safety of DOACs in hypercoagulable states related to cholangiocarcinoma. Prospective investigations of DOACs efficacy in secondary stroke prevention in this population are warranted.