A 61-year-old Korean woman was admitted to the Department of Vascular Surgery, presenting with a tingling sensation on both lower legs and vague chest discomfort for one month. She was a never smoker and had dyspnea (3 on Medical Research Council scale) for two weeks but no fever. She had undergone surgical excision of a benign mass of the left breast and hysterectomy due to uterine prolapse, 15 and five years ago, respectively; denied any postoperative complications and history of renal or hepatic disease. Computed tomogram (CT) angiography of the chest did not show evidence of pulmonary thromboembolism. However, 2×1.2-cm-sized nodular lesion in left lingular division abutting to mediastinal pleura and lymphadenopathies on the left paraaortic and supraclavicular area and both prevascular and subaortic area were noted (
Figure 1). Clots in the popliteal and calf vein of the right leg were noted on a CT angiogram for the pelvis and legs (
Figure 2). The patient was immediately started on treatment with continuous administration of intravenous heparin. An extensive laboratory work-up was performed in search of underlying hypercoagulability disorders (
Table 1). On the fourth day, she was transferred to Department of Center for Lung Cancer for further evaluation of lung cancer. No endobronchial lesion was observed on bronchoscopic examination. Adenocarcinoma was diagnosed pathologically on a biopsy specimen of supraclavicular lymph node. Thyroid transcription factor-1 was positive on immunohistochemistry and activating mutation of epidermal growth factor receptor gene was not demonstrated. On the fifth day, palsy of the lateral gaze of both eyes and double vision was developed suddenly. She underwent brain magnetic resonance angiogram, which demonstrated subacute stage of embolic infarctions on territories of both the middle and posterior cerebral arteries and the right cerebellar hemisphere (
Figure 3). Neither stenotic flow nor visible plaque was demonstrated in Doppler ultrasound examination for both carotid arteries. No evidence of distant metastasis was observed on brain magnetic resonance image (MRI), bone scan, and positron emission tomography. Finally, her disease was staged as IIIB; however, she did not want to receive any treatment for her lung cancer. On Transthoracic echocardiogram, vegetation measuring 9 mm in size was observed on the posterior mitral leaflet with moderate mitral regurgitation and the basal inferior wall was akinetic with 50% of left ventricular ejection fraction (
Figure 4A). Blood culture of the patient revealed no evidence of bacteremia. Diffuse irregular stenosis (30% of diameter) of the distal portion of the left anterior descending artery and diffuse irregular stenosis (80% of diameter) of the posterolateral branch of the right coronary artery were observed on coronary angiogram (
Figure 4B). Intracoronary injection was administered with ReoPro (Abciximab, Eli-Lilly, Indianapolis, IN, USA) and thrombus was aspirated from the right coronary artery. On the eighth day, heparin was switched to warfarin. On the 15th day, follow-up transthoracic echocardiogram showed a decrease in size of the vegetation (4 mm), improvement of mitral regurgitation (mild degree), and normalization of left ventricular ejection fraction. She was discharged on the 17th day. Three weeks later, she visited to the emergency room with sudden development of dysarthria, aphasia, and right hemiplegia. A newly demonstrated hyperacute embolic infarction in the operculum area of the left frontal-parietal junction was observed on her brain MRI. She is receiving rehabilitation treatment for her hemiplegia.