Abstract: Objective To analyzed the clinical imaging characteristics and high-risk factors of patients with active cancer related stroke (ACS). Methods A total of 86 patients who were diagnosed with ACS in the Affiliated Hospital of Xuzhou Medical University from January 2012 to December 2020 were enrolled as an ACS group. Meanwhile, another 86 active cancer patients without cerebral infarction were included as an AC group. Both groups were compared for clinical characteristics, and the related factors affecting the occurrence of cerebral infarction in patients with active cancer were discussed. The ACS group was further divided into two groups: a single vascular territory (SV) group and a multiple vascular territory (MV) group. Their imaging characteristics of cerebral infarction in active cancer patients were analyzed. Results Among ACS patients, lung cancer was the most common type. Patients with TNM stage IV accounted for the highest proportion, and adenocarcinoma was the most common histopathological type. Compared with the AC group, the ACS group showed increases in the levels of inflammatory markers such as white blood cells, neutrophils, neutrophil-lymphocyte ratio, and hs-CRP (all P<0.05), as well as an increased proportion of patients with tumor markers carbohydrate antigen (CA) 125>35 000 U/L (P<0.05), and an increased incidence of disseminated intravascular coagulation (DIC) (P<0.05). Conditional logistic regression analysis showed that plasma D-dimer (≥5 mg/L), controlling nutritional status (Conut) score, and more than two vascular risk factors (including hypertension, diabetes, smoking, alcohol drinking and hyperlipidemia) were independently associated with cerebral infarction in AS patients (P<0.05). In the ACS group, the number of patients in the MV group was 51 cases (59.3%), where 49% had lesions involving three vascular territories (the bilateral anterior circulation and posterior circulation). Moreover, there was statistical difference in fibrinogen, hs-CRP, DIC and D-dimer (≥5 mg/L) between the MV and SV groups (P<0.05). Conclusions Hypercoagulability, vascular risk factors, and malnutrition may be the important factors associated with ACS. Multiple lesions involving multiple-vascular territories are the imaging characteristics of active cancer patients, and inflammatory effects and hypercoagulability may contribute to the occurrence of ACS.