Supplementary Material for: New Diagnosis of Adrenocortical Carcinoma with Stroke Work Up

Introduction
Ischemic stroke has well-established risk factors such as hypertension, diabetes, hyperlipidemia and atrial fibrillation. However, strokes can also occur in the context of less common etiologies such as malignancies, particularly as certain malignancies are associated with hypercoagulable states. Adrenocortical carcinoma (ACC) is unique malignacy in relation to stroke as it can also present with a hypercortisolemic state, which can further exacerbate cancer coagulopathy and the traditional metabolic risk factors of stroke.

Case Presentation
A 60 year old woman presented with expressive aphasia and was found to have multifocal acute infarcts on magnetic resonance imaging. She underwent a thorough cardiac, coagulopathy and paraneoplastic work up and was found to have a right adrenal mass and was biochemically hypercortisolemic. The patient underwent surgical resection of the adrenal mass and pathology confirmed the diagnosis of adrenocortical carcinoma.

Conclusion
The discovery of this rare malignancy underscores the complex interplay between malignancy, hormonal imbalances, hypercoagulability in stroke and the importance of a comprehensive clinical diagnostic evaluation.