# Stroke as an Initial Presentation of Hepatocellular Carcinoma: A Case Report

## TL;DR

A case report shows that stroke can be the first sign of liver cancer, highlighting the need for cancer screening in such patients.

## Contribution

This case highlights stroke as a rare initial presentation of hepatocellular carcinoma, emphasizing the importance of malignancy screening in cryptogenic stroke.

## Key findings

- A 46-year-old patient presented with stroke and was later diagnosed with hepatocellular carcinoma.
- Elevated D-dimer and multifocal infarcts prompted further investigation leading to cancer detection.
- The case underscores the need for abdominal imaging in stroke patients with unexplained hypercoagulability.

## Abstract

Malignancy and ischemic stroke are major causes of global morbidity and mortality. Thromboembolic strokes secondary to malignancy are uncommon but represent a critical consideration in cryptogenic stroke. We report the case of a 46‐year‐old female with no significant past medical history who presented with acute rightward gaze deviation. Brain MRI confirmed acute multifocal ischemic infarcts. An extensive workup, including CT angiography and echocardiography, ruled out common stroke mechanisms, leading to a diagnosis of embolic stroke of undetermined source (ESUS) per 2021 AHA guidelines. This prompted a hypercoagulability workup, which revealed a markedly elevated D‐dimer. Subsequent investigation showed elevated liver enzymes, and abdominal imaging identified a hepatic mass with contrast‐enhanced CT features highly suggestive of hepatocellular carcinoma (HCC). The patient was transferred to oncology services for HCC management. At discharge, her neurological symptoms had partially improved, but she was lost to long‐term follow‐up, and thus her final oncological outcome is unknown.

Stroke can be the initial manifestation of occult hepatocellular carcinoma. Unexplained elevated D‐dimer and multifocal infarcts should prompt malignancy screening, including abdominal imaging, even in patients without typical cancer symptoms or liver test abnormalities. Early detection may guide appropriate oncologic and stroke management.