# Trousseau Syndrome-Associated Acute Multifocal Cerebral Infarction: When Triple-Pathway Antithrombotic Therapy Overcomes Low Molecular Weight Heparin Resistance

## TL;DR

A rare case of Trousseau syndrome caused severe brain infarction, and triple-pathway antithrombotic therapy helped overcome resistance to standard treatment.

## Contribution

Demonstrates successful use of triple-pathway antithrombotic therapy in overcoming LMWH resistance in Trousseau syndrome.

## Key findings

- Patient presented with rare acute multifocal cerebral infarction due to Trousseau syndrome.
- Nadroparin failed to anticoagulate, but argatroban, clopidogrel, and cilostazol prevented further complications.
- Triple-pathway therapy offers a potential paradigm for managing refractory hypercoagulable states.

## Abstract

Trousseau syndrome (TS), a malignancy-associated hypercoagulable state characterized by both arterial and venous synchronous thrombotic events, represents a critical clinical challenge. We present a 63-year-old male with hepatocellular carcinoma metastases who presented to the Emergency Department with acute-onset unconsciousness. Neurological evaluation revealed rare documentation of extensive multifocal cerebral infarcts accompanied by diffuse vascular thrombosis, atherosclerotic plaque burden, and markedly elevated D-dimer levels, establishing the diagnosis of TS. The initial infusion of nadroparin, which was co-administered with aspirin, achieved almost no anticoagulation. Consequently, the strategy was escalated to triple-pathway antithrombotic therapy through substitution with argatroban, clopidogrel, and cilostazol. This regimen successfully prevented further thrombotic complications. This case provides rare documentation of catastrophic cerebral parenchymal involvement secondary to TS. Furthermore, the effective application of anticoagulation-antiplatelet combination therapy following low-molecular-weight heparin (LMWH) resistance offers a potential management paradigm for refractory hypercoagulable states.