What happened, in summary

This 78-year-old man was referred for surgical treatment of lung cancer. He had hypertension, diabetes, a history of surgical resection for renal pelvic cancer, and a 118 pack-year smoking history. Bronchoscopic biopsy confirmed adenocarcinoma in the right middle lobe of the lung. Preoperative staging was cT1bN0M0 / Stage IA2, with no reported lymph-node or distant spread. He underwent video-assisted thoracoscopic right middle lobectomy with ND2a-2 lymph-node dissection. The operation lasted 2 hours and 42 minutes, and estimated blood loss was 40 mL. He began mobilizing on postoperative day 1. Later that same day, while escorting visitors, he suddenly collapsed and developed incomplete right-sided weakness with motor aphasia. Head CT showed no hemorrhage, but diffusion-weighted MRI showed acute infarction in the left frontal lobe involving anterior and middle cerebral artery territories. Cerebral angiography did not show major vessel blockage, so mechanical thrombectomy was not indicated. The stroke was first treated as embolic stroke of undetermined source, and aspirin was started on postoperative day 2. A detailed search for the embolic source followed. Holter monitoring showed no arrhythmia, chest CT showed no cardiac or pulmonary vein stump thrombus, and leg ultrasound showed no deep vein thrombosis. A bubble-test echocardiogram found a patent foramen ovale, supporting paradoxical brain embolism as the likely mechanism. Aspirin was switched to apixaban. He transferred to rehabilitation on postoperative day 23, and his weakness and aphasia markedly improved. At 10 months after surgery, he had no recurrence of lung cancer or stroke. His cancer remained controlled despite the early neurologic complication.