paraneoplastic neurological manifestations in cancer patients are common and may precede the diagnosis of malignancy . in particular , the incidence of stroke in patients with cancer is notably higher than in the general population . ischaemic stroke results mainly from a state of hypercoagulability , atherosclerosis or nonbacterial thrombotic endocarditis . however , a first - ever stroke revealing an undiagnosed , underlying malignancy is a very rare event with a poor outcome . a patent foramen ovale ( pfo ) is a common cardiac anomaly with a reported incidence of 1735  % , based on autopsy studies some studies have suggested that unexplained strokes due to pfos occur in 1241  % of the population studied [ 2 , 3 ] . to the best of our knowledge , this is a rare case report of a paradoxical embolism in a patient with pancreatic cancer . a 69-year - old woman was referred to our emergency department with a few days history of malaise , followed by acute aphasia . a neurological examination showed monoparesis of the right arm , aphasia and babinski s sign on the right side . the patient did not show any signs of endocarditis , and auscultation of the heart did not reveal any abnormalities . laboratory analyses revealed slightly elevated inflammation parameters , hepatic dysfunction , leucocytosis and normocytic anaemia ( aspartate aminotransferase , 87 ( normal value , <  40 ) u / l ; alanine transaminase , 90 ( <  45 ) u / l ; c - reactive protein , 103 ( <  10 ) mg / l ; haemoglobin , 6.8 ( 7.510.0 ) mmol / l ; mean corpuscular volume , 83 ( 8298 ) fl ; leucocytes , 16.7    10 ( 4.511.0)/l ) . the ecg showed a normal sinus rhythm without conduction abnormalities and without signs of pulmonary hypertension or left ventricular hypertrophy . cerebral computed tomography ( ct ) revealed focal , hypodense lesions on multiple sites within different vascular territories ( fig .  1 ) . 1computed tomography axial of the brain showing multiple hypodense subcortical areas suggestive of ischaemia computed tomography axial of the brain showing multiple hypodense subcortical areas suggestive of ischaemia on admission , the patient s differential diagnosis included vasculitis , septic / embolic encephalopathy due to endocarditis or a paraneoplastic embolism . transthoracic echocardiography ( tte ) revealed an atrial septal defect , without any valve abnormalities . these observations , in combination with the cerebral imaging , allowed the final diagnosis of paraneoplastic embolism . thoracic and abdominal ct identified the probable cause of the hypothesised paraneoplastic hypercoagulable state : pancreatic cancer ( cauda ) with liver and adrenal metastasis ( fig . because of the poor prognosis for this condition , further investigations were not conducted and palliative care was provided at home . 2computed tomography showing a pancreatic lesion , suspect for pancreatic cancer computed tomography showing a pancreatic lesion , suspect for pancreatic cancer in this case report , we demonstrate that tte is a valuable tool in the diagnosis of unexplained , embolic , ischaemic , cerebral stroke in a patient with a hypercoagulable state due to an unknown cancer . the incidence of hypercoagulability in patients with cancer varies between 1 and 11  % clinically , and by up to 50  % in autopsy series . arterial thromboembolisms are very rare , but hypercoagulability , induced by malignancy , is a cause of unexplained intravascular thrombosis . under these conditions , endothelial cells may express cytokine - regulated procoagulant factors , and elevated platelet reactivity due to platelet  tumour interactions may also contribute to the hypercoagulable state . in 1865 , trousseau was the first to describe migratory , superficial thrombophlebitis . he linked this hypercoagulable state with malignancies , usually mucin - producing adenocarcinomas and digestive cancers . in pancreatic cancers , there is a particularly high risk of a tumour in the corpus / cauda , compared with in the caput . the presence of a paradoxical embolism through a pfo , which has a reported prevalence of up to 35  % of the normal population , might be responsible for more arterial embolic events than is currently understood . in our patient , screening for occult cancer in a patient with a first - ever stroke or thrombosis is not cost - effective ; an active search for such cancer is only indicated in the subgroup of patients with a suspected malignancy . however , echocardiography is essential in patients showing cerebral ischaemic stroke within different vascular territories . echocardiography ( sensitivity , 88  % ; specificity , 97  % ) , initially coupled with lower - extremity venous doppler ultrasound , is both simple and noninvasive , and should therefore be included in the diagnostic evaluation of a multivascular embolic stroke . unfortunately , due to the emergency setting , no proper data storage of the echocardiographic images was performed in our patient . this was a rare case of a patient who had signs and symptoms of a first - ever embolic stroke as the initial presentation of pancreatic cancer ; tte was essential in establishing the diagnosis . in our patient , the only finding that was linked with the embolic , ischaemic stroke was the large pfo . this , in combination with the hypothesised hypercoagulability due to malignancy , makes a paradoxical embolism the probable cause of the stroke . if a patient presents with signs and symptoms of embolic ischaemic stroke , a pfo with paradoxical embolism should be considered . however , in patients with multivascular embolic stroke , tte is essential in establishing the diagnosis and should therefore be a standard procedure .
we describe a patient admitted to the intensive care unit with aphasia , which was due to an embolic ischaemic cerebral stroke associated with a previously unknown patent foramen ovale . eventually , this finding during echocardiography led us to the diagnosis of pancreatic cancer . 
 the thrombotic complications of pancreatic cancer , in combination with a large , patent foramen ovale , support the mechanism of a paradoxical embolism through the patent foramen ovale as the cause of cerebral ischaemic stroke .