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

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.