Three-territory sign (brain)
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At the time the article was created Rohit Sharma had no recorded disclosures.
View Rohit Sharma's current disclosuresAt the time the article was last revised Arlene Campos had no financial relationships to ineligible companies to disclose.
View Arlene Campos's current disclosures- 3-territory sign
- Three territory sign
The three-territory sign is a radiological sign described in ischemic stroke and is highly specific to hypercoagulability due to malignancy (Trousseau syndrome) being the etiology. However, this sign is not pathognomonic, and may be seen with cardioembolic stroke (e.g. due to atrial fibrillation, endocarditis, cardiac tumors) or stroke due to other prothrombotic states (e.g. due to COVID-19) 1-7.
The three-territory sign describes ischemic strokes involving three vascular territories including involvement of the bilateral anterior and posterior circulations 1-6. Often, the individual ischemic strokes are small, rather than being large vessel occlusions 3. The sign is best appreciated with diffusion-weighted imaging on MRI 1-6.
In one study, the three-territory sign was found to be highly specific (96.4%) but not sensitive (23.4%) for hypercoagulability due to malignancy (Trousseau syndrome) 1. Notably, in the same study, the three-territory sign was six times more likely observed in patients with underlying malignancy when compared to patients with underlying atrial fibrillation who may have had multi-territory cardioembolic ischemic stroke (i.e. embolic shower) 1. In another study, the three-territory sign was found to be an independent marker of increased mortality in patients with acute ischemic stroke in the setting of malignancy 6.
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See also
References
- 1. Nouh A, Staff I, Finelli P. Three Territory Sign: An MRI Marker of Malignancy-Related Ischemic Stroke (Trousseau Syndrome). Neurol Clin Pract. 2019;9(2):124-8. doi:10.1212/CPJ.0000000000000603 - Pubmed
- 2. Finelli P. MR Three-Territory Sign in Cancer-Associated Hypercoagulation Stroke (Trousseau Syndrome). Neurologist. 2021;27(2):37-40. doi:10.1097/nrl.0000000000000356 - Pubmed
- 3. Finelli P & Nouh A. Three-Territory DWI Acute Infarcts: Diagnostic Value in Cancer-Associated Hypercoagulation Stroke (Trousseau Syndrome). AJNR Am J Neuroradiol. 2016;37(11):2033-6. doi:10.3174/ajnr.A4846 - Pubmed
- 4. Bhatele P, Das A, Pandit A, Radhakrishnan D, Srivastava A. Three Territory Sign in COVID-19. Acta Neurol Belg. 2022;122(6):1601-2. doi:10.1007/s13760-021-01842-8 - Pubmed
- 5. Toda Y & Kano Y. Three-Territory Sign in Trousseau’s Syndrome. BMJ Case Rep. 2022;15(11):e253520. doi:10.1136/bcr-2022-253520 - Pubmed
- 6. Cheng Y, Ning Y, Zhao Y, Cao X, Liu H, Shi T. Association Between Three-Territory Sign and Prognosis of Acute Ischemic Stroke Patients with Malignancy. Front Neurol. 2023;14:1265715. doi:10.3389/fneur.2023.1265715 - Pubmed
- 7. Figueroa M, Kazmirczak F, Hashtjin S, Streib C. A Novel Mechanism of the “Three Territory Sign” in Acute Ischemic Stroke (P14-5.014). Neurology. 2023;100(17_supplement_2). doi:10.1212/wnl.0000000000204004
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