Stroke in patients with cancer: Incidence and etiology

Risk Factors for Gastric Cancer-Associated Thrombotic Diseases in a Han Chinese Population

The aim of the present work was to investigate the risk factors for gastric cancer- (GC-) associated thrombotic diseases in a Han Chinese population. A total of 333 patients diagnosed with GC, 68 with thrombotic diseases included in the case group and the remaining 265 in the control group, were enrolled. The relevant data for the participants, including general information (gender, age, smoking, and drinking), comorbidities (diabetes, hypertension, and anemia), tumor-related data (tumor site, histology, degree of differentiation, and clinical stage), and treatment-related data (surgery, chemotherapy, hormones, transfusion, and peripherally inserted central venous catheter (PICC)), were collected. Statistically significant factors derived from univariate analyses were then subjected to multivariate logistic regression analyses. The results demonstrate a statistically significant difference in age, diabetes, hypertension, histology, surgery, chemotherapy, and PICC (P < 0.05), compared with control. Age, diabetes, surgery, and PICC serve as independent risk factors for GC-associated thrombotic diseases (P < 0.05). The present work demonstrates that GC-associated thrombotic diseases are significantly associated with age, diabetes, surgery, and PICC, suggesting a potential target for early detection and preventive strategy for GC patients with thrombophilia.

Stroke in patients with cancer in the era of hyper-acute stroke intervention

OBJECTIVE

The natural history of patients with stroke and cancer remains poorly understood in the modern era of hyper-acute stroke therapies (recombinant tissue plasminogen activator (tPA) and endovascular clot retrieval (ECR)). Prior to these advances in stroke treatment, a highly cited study reported median overall survival (mOS) 4.5 months after stroke in a cohort of patients with cancer (2004, n=96). Our aim is to evaluate outcome following stroke for patients with cancer in this modern era. Our hypothesis is that patients with stroke and cancer have better outcome than in earlier studies.

DESIGN AND SETTING

Retrospective analysis of admission to a tertiary Stroke Unit between January 2015 and September 2017 (N=1910), evaluation of hospital records and cancer treatment records.

OUTCOME MEASURES

Cancer was categorised as early stage (stage I and II) and advanced stage (stage III or IV, using the RD-Staging system). Survival analysis was performed in R.

RESULTS

There were 143 stroke patients with cancer (62% male) with mean age 73.2 +/- 12.5 years. Ischemic stroke occurred in 74.1% and 45 of 106 patients (42.5%) received intravenous thrombolysis (34/45) and / or endovascular clot retrieval (11/45). One patient who received ECR died within 30-days of stroke. Those with early-stage disease had mOS of 19.6 months (IQR 3.1, 31.5 months) and in advanced stage cancer mOS was 2.5 months (IQR 0.4, 6.3 months, p<0.01) CONCLUSION: In the modern era of stroke therapy, our cohort of patients with advanced cancer have lower survival post-stroke compared to those with early-stage cancer. This article is protected by copyright. All rights reserved.

Neuro-Oncologic Emergencies

Cancer and cancer therapies have the potential to affect the nervous system in a host of different ways. Cerebral edema, increased intracranial pressure, cerebrovascular events, status epilepticus, and epidural spinal cord compression are among those most often presenting as emergencies. Neurologic side-effects of cancer therapies are often mild, but occasionally result in serious illness. Immunotherapies cause autoimmune-related neurologic side-effects that are generally responsive to immunosuppressive therapies. Emergency management of neuro-oncologic problems benefits from early identification and close collaboration among interdisciplinary team members and patients or surrogate decision-makers.

Left pneumonectomy for primary lung cancer with Trousseau's syndrome

Trousseau's syndrome is a paraneoplastic syndrome and a pathological condition that causes cerebral stroke symptoms due to hypercoagulation associated with malignant tumours. There have been many cases of advanced lung cancer, but few reports have described surgery for lung cancer with Trousseau's syndrome. We encountered a 76-year-old man suspected of having Trousseau's syndrome associated with lung cancer. He was transferred to our hospital on the second day after the onset. After admission, he was treated with heparin and edaravone, and his condition improved. On the 12th day after the onset, we performed left pneumonectomy and lymph node dissection (ND2a-2). The final pathological results were adenocarcinoma, pathological stage was T4 (tumour size: 77 mm, pulmonary artery invasion) N1(#11, #12u) M0, stage IIIA. He has been recurrence free for 23 months since the surgery. In the future, we need to follow his condition carefully.

Seizures, Edema, Thrombosis, and Hemorrhages: An Update Review on the Medical Management of Gliomas

Patients affected with gliomas develop a complex set of clinical manifestations that deeply impact on quality of life and overall survival. Brain tumor-related epilepsy is frequently the first manifestation of gliomas or may occur during the course of disease; the underlying mechanisms have not been fully explained and depend on both patient and tumor factors. Novel treatment options derive from the growing use of third-generation antiepileptic drugs. Vasogenic edema and elevated intracranial pressure cause a considerable burden of symptoms, especially in high-grade glioma, requiring an adequate use of corticosteroids. Patients with gliomas present with an elevated risk of tumor-associated venous thromboembolism whose prophylaxis and treatment are challenging, considering also the availability of new oral anticoagulant drugs. Moreover, intracerebral hemorrhages can complicate the course of the illness both due to tumor-specific characteristics, patient comorbidities, and side effects of antithrombotic and antitumoral therapies. This paper aims to review recent advances in these clinical issues, discussing the medical management of gliomas through an updated literature review.

Embolic Stroke Due to a Mural Thrombus in the Ascending Aorta Following Cisplatin-based Chemotherapy

A 59-year-old woman with small-cell lung carcinoma achieved tumor disappearance after cisplatin-based chemotherapy (CBC) and radiation treatment but subsequently experienced right hemiparesis and aphasia. Brain magnetic resonance imaging revealed a left middle cerebral artery territory acute infarction and left internal carotid artery occlusion. Ultrasonography revealed a mobile thrombus in the left common and internal carotid arteries, and contrast computed tomography revealed a mural thrombus in the ascending aorta. Based on these findings, embolic stroke due to aortic mural thrombus following CBC was diagnosed. Aortic mural thrombus is a rare complication of CBC but carries a risk of embolic stroke.

Risk of stroke in cancer survivors using a propensity score-matched cohort analysis

Little is known about the risk of cerebrovascular disease in cancer survivors. We aimed to assess the association between incident cancer and the subsequent risk of stroke using a large-scale, population-based prospective study. 74,530 Japanese aged between 40 and 69 years at baseline study were matched by the status of cancer diagnosis during follow-up using propensity score nearest-neighbor matching with allowance for replacement. A total of 2242 strokes were reported during 557,885 person-years of follow-up. Associations between incident cancer and the subsequent risk of all strokes, cerebral infarction, and intracerebral hemorrhage were assessed using a Cox proportional hazards model stratified on the propensity score-matched pairs. No significant association was observed between the status of cancer diagnosis of all types, gastric, colorectal and lung cancer, and subsequent occurrence of all strokes, cerebral infarction, and intracerebral hemorrhage. However, analysis by discrete time periods suggested an elevated risk in cancer patients for one to three months after a cancer diagnosis in all stroke (HR, 2.24; 95% CI, 1.06, 4.74) and cerebral infarction (HR, 2.62; 95% CI, 1.05, 6.53). This prospective cohort study found no association between the status of cancer diagnosis and the subsequent occurrence of all strokes and its subtypes during the entire follow-up period but suggested an increase in stroke risk during the active phase of malignancy.

Neurologic complications of nonbacterial thrombotic endocarditis

Endocarditis is an inflammatory or infective condition affecting the cardiac valves or endocardium, often associated with serious neurological sequelae. Nonbacterial thrombotic endocarditis (NBTE)-referred to as degenerative, Libman-Sachs, marantic, verrucous, or terminal endocarditis-is a serious but rare cause of valvular heart disease characterized by deposition of sterile vegetations of fibrin and platelet aggregates on the cardiac valves, eventually resulting in life-threatening embolization of these thrombi to the brain, limbs, or visceral organs. NBTE may complicate a heterogeneous group of chronic conditions, predominantly connective tissue and autoimmune disorders, malignancies, and diseases associated with hypercoagulability states. NBTE usually affects the native rather than prosthetic valves, and unlike infective endocarditis (IE), sparing the involved valve function without its destruction. Compared to those seen in IE, vegetations in NBTE are small and friable, thus may easily be dislodged leading to systemic thromboembolism with devastating morbidities and mortality. There are no diagnostic criteria for NBTE, and antemortem diagnosis is challenging. The condition should be suspected in patients with thromboembolic events and vegetations on the cardiac valves on echocardiographic or cardiac imaging studies, in the absence of underlying infection, especially in disorders predisposing to coagulopathy. Early recognition and prompt treatment of the primary underlying disorder is essential. Anticoagulation with heparin or heparinoid products is recommended to prevent recurrent embolism. Surgical intervention is not indicated except in selected patients with life-threatening recurrent embolism.

The incidence of myocardial infarction and stroke in head and neck cancer patients

Various treatment modalities are used for head and neck cancer (HNC). This study analyzed the incidence and risks of myocardial infarction (MI) and stroke by cancer site and treatment modality in 22,737 patients newly diagnosed with HNC registered in the Korean National Health Insurance Service database in 2007–2013. An additional 68,211 patients without HNC, stroke, or MI were identified as the control group. The risks for MI (hazard ratio [HR] = 1.38, 95% confidence interval [CI] 1.24–1.53), stroke (HR = 1.48, 95% CI 1.37–1.60), and mortality (HR = 5.30, 95% CI 5.14–5.47) were significantly higher in the HNC group. Analysis by cancer site showed the risk of MI and mortality was highest in hypopharynx cancer, while the risk of stroke was highest in nasopharynx and paranasal sinus cancer. Analysis by treatment modality showed the highest risks for MI (HR = 1.88, 95% CI 1.31–2.69) and mortality (HR = 2.95, 95% CI 2.75–3.17) in HNC patients receiving chemotherapy (CT) alone, while HNC patients receiving CT with surgery had the highest risk for stroke (HR = 1.81, 95% CI 1.14–2.88). Careful attention to MI and stroke risks in HNC patients is suggested, especially those who received both CT and radiotherapy.

Contribution of Immune-Mediated Paraneoplastic Syndromes to Neurological Manifestations of Neuroendocrine Tumours: A Retrospective Study

INTRODUCTION

Neurological symptoms associated with neuroendocrine tumours (NETs) may be related to metastatic disease or paraneoplastic syndromes (PNSs); these last are often associated with autoantibodies targeting various onconeural antigens. To better characterize neurological PNSs related to NETs, we report the largest case-series study to date.

METHODS

We retrospectively reviewed the charts of all patients diagnosed with NETs of the gastrointestinal tract who presented with neurological symptoms at either of 2 tertiary academic hospitals (Henri Mondor and Beaujon, France) between 1994 and 2016. All patients underwent extensive neurological tests including clinical, laboratory, and radiological investigations. The clinical response to immunomodulating agents was recorded.

RESULTS

In the 13 identified patients, the most common presentations were peripheral neuropathy (46.2%) and encephalopathy (26.6%). Of the 6 (53.3%) patients whose serum anti-neuronal antibodies were assayed, 5 had high titres. Short-term oral corticosteroid and immunosuppressant drug therapy was given to 4 of these patients, of whom 3 had a clinical response and 1 no response. Repeated high-dose intravenous immunoglobulin therapy induced a complete clinical response in 1 patient. Encephalopathy resolved fully after hepatectomy or intrahepatic chemoembolization for liver metastases in another 2 patients.

DISCUSSION

The neurological symptoms associated with NETs may be due in part to autoimmune PNS. Based on experience at our 2 centres, we estimate that autoimmune PNS occurs in about 1% of patients with NETs. Early symptom recognition allows the initiation of effective treatments including corticosteroids, immunosuppressive drugs, and/or intravenous immunoglobulins.

Lung adenocarcinoma initially presenting as Trousseau's syndrome treated successfully with pembrolizumab: A case report

A 60-year-old woman was urgently admitted to our hospital because of vertigo and left hemiplegia. Laboratory examination showed thrombocytopenia, high levels of D-dimer and carcinoembryonic antigen. Brain magnetic resonance imaging (MRI) revealed multiple bilateral cerebral infarctions. Chest computed tomography (CT) showed an irregularly shaped tumor in the upper lobe of the left lung and mediastinal node swelling. The histopathological findings revealed adenocarcinoma negative for anaplastic lymphoma kinase fusion gene, sensitive epidermal growth factor receptor mutations. A diagnosis of lung adenocarcinoma initially presenting as arterial thromboembolism was made, and she was treated with direct oral anticoagulant (DOAC). Subsequently, pembrolizumab therapy was initiated because tumor cells were positive for programmed cell death protein 1 (PD-L1;60%), and resulted in reduction of the tumor with normalization of the platelet count and d-dimer. The treatment has been continued for over one year without any recurrence of the disease or thromboembolism.

Endovascular Therapy of Acute Ischemic Stroke in Patients with Large-Vessel Occlusion Associated with Active Malignancy

PURPOSE

There is limited data on the effectiveness of endovascular therapy (EVT) in stroke patients with active malignancy. In this study, we investigated the outcome of EVT for acute ischemic stroke for patients with active malignancy compared to those without malignancy.

METHODS

We selected patients who underwent EVT for acute ischemic stroke between January 2015 and July 2019. Patients were divided into two groups, those with active malignancy (oncology group - OG) and those without (non-oncology group, NOG).

RESULTS

300 patients were included in this study. There were 19 EVT procedures (18 patients) in the OG and 285 procedures (282 patients) in the NOG. There was no difference in recanalization success rate (mTICI 2b & 3) between the groups: 94.7% versus 80.9% in OG and NOG respectively (p = 0.13). Success rate using the direct aspiration (ADAPT) technique of EVT was not different between compared groups (42.9% versus 67.7%; p = 0.18). However, when using smaller-caliber aspiration devices, ADAPT was less successful in OG (0.0% versus 64.7%, p < 0.05). There was no difference in recanalization success rate of EVT when using a stent-retriever or combined technique. Patients in the OG had a less favorable functional outcome than in the NOG group (mRS 0-2 at 90-days post event: 22.2% versus 48.2%, p < 0.05) CONCLUSION: The technical success rate of EVT in patients with active malignancy is similar to the general population of stroke patients. Interestingly, the success rate of EVT using the ADAPT technique was lower in the OG when using smaller caliber aspiration devices.

Trousseau's syndrome associated with rapidly emerging pancreatic adenocarcinoma soon after esophagectomy: A case report

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The first reported case of Trousseau’s syndrome associated with rapidly emerging pancreatic cancer potentially triggered esophagectomy.

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The aggressively emerging pancreatic cancer with mucin production may be a potential mechanism for cancer-related thrombosis.

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When a patient with cancer encountered small, multiple cerebral infarctions postoperatively, the body should be checked for occult malignancy.

Introduction

Trousseau’s syndrome is characterized as an unexpected, cancer-associated thrombotic event. We describe the first reported case of Trousseau’s syndrome associated with rapidly emerging pancreatic cancer potentially triggered by esophagectomy.

Presentation of case

A 79-year-old asymptomatic male with clinical stage I esophageal squamous cell carcinoma underwent thoracoscopic subtotal esophagectomy. On postoperative day 46, the patient presented with weakness of his left upper extremity due to multiple cerebral and cerebellar infarctions, with no evidence of atherosclerotic or cardiogenic thrombi. An abdominal computed tomography (CT) showed a pancreatic tumor with multiple liver metastases. Extremely high D-dimer and the CT findings suggested Trousseau’s syndrome associated with a rapidly emerging neoplasm as the etiology of the brain infarction. Although further thrombotic events did not occur, his condition deteriorated rapidly and died on the 31st days of onset. The autopsy revealed multiple small infarctions, with multiple thrombi in the cerebral hemispheres, brain stem, and cerebellum. Histological evaluation revealed pancreatic adenocarcinoma with nodal and liver metastases.

Discussion

A hypercoagulable state associated with the aggressively emerging pancreatic adenocarcinoma, accompanied by cancer cell production of mucin, may be a potential mechanism for cancer-related thrombosis.

Conclusion

In patients who received intensive surgical treatment and encountered unexplained brain infarctions in the multi-arterial territory, Trousseau’s syndrome should be considered, and investigation for occult malignancy is required.

The Risk Factors for Death within 6 Months After Ischemic Stroke in Patients with Cancer

OBJECTIVES

While the intravenous recombinant tissue plasminogen activator (rt-PA) therapy for acute ischemic stroke patients with cancer is recommended when survival of ≥ 6 months is expected, the risk factors for death and stroke recurrence within 6 months after stroke are not well known. Thus, we aimed to identify markers for death and recurrence risks within six months from stroke onset in patients with cancer.

MATERIALS AND METHODS

In a retrospective cohort study, the subjects comprised acute ischemic stroke patients with cancer hospitalized at St. Marianna University hospital from 2008 through 2019. To evaluate the associations between the clinical factors within 24 h of the initial stroke and death or stroke recurrence events within 6 months from stroke onset, Logistic analysis and Cox proportional hazards regression analysis was used respectively. Next, the optimal cutoff point of markers for different mortality groups was determined using the receiver operating characteristic curve analysis and cumulative outcome rate of each group was compared using the Kaplan-Meier method.

RESULTS

Among 194 patients with cancer who developed acute stroke, 167 were ultimately selected for analysis. 47 subjects (28.14%) passed away within 6 months following stroke onset, and 20 subjects (11.98%) had stroke recurrence. High D-dimer levels, low fibrinogen levels, high Glasgow prognostic scores (GPS), and multiple vascular territory infarctions was independently associated with death, where higher death rate was significantly confirmed in the group with D-dimer levels of ≥3.95 mg/dl, fibrinogen levels <277.5 mg/dl and GPS scores of 2. Low fibrinogen level, lack of antithrombotic therapy, and the presence of metastasis were associated with stroke recurrence.

CONCLUSIONS

When patients with cancer suffer stroke, D-dimer levels, fibrinogen levels, GPS, and multiple vascular territory infarctions would be associated with the risk of death within 6 months. Low fibrinogen levels, lack of antithrombotic therapy, and the presence of metastasis correlated with high risk of stroke recurrence.

Clinical Characteristics and Analysis of Lung Cancer- Associated Acute Ischemic Stroke

INTRODUCTION

The incidence of lung cancer and acute ischemic stroke remains high in recent years, both of which occur mostly in people over 60 years old. In the present study, we aimed to further clarify the pathogenesis of lung cancer-associated acute ischemic stroke (LCA-AIS) by comparing and analyzing clinical characteristics of stroke patients with or without lung cancer.

METHODS

A total of 51 patients with lung cancer were selected as the case group (LCSG), and 78 patients without cancer history were adopted as the control group (SG). The data collected in this study included sex, age, traditional cerebrovascular disease risk factors (TCDRFs), blood test index, imaging findings, etiological typing, and prognosis evaluation. SPSS21.0 software was used for statistical analysis. Normally distributed data were analyzed by t-test, and count data were analyzed by chi-square test or exact probability method. P < 0.05 was considered statistically significant.

RESULTS

In the case group, the levels of plasma D-dimer, fibrinogen degradation products (FDPs) and NIHSS, as well as the mRS score and mortality of patients, were higher, while the levels of RBC, Hb and Hcy were lower compared with the control group. Imaging findings showed that multivessel involvement was more common in the case group, and the infarcts were more likely to be multiple and involved in both the anterior and posterior circulations. The TOAST classification of LCSG was dominated by stroke of undetermined etiology (SUE) and stroke of other determined etiology (SOE). Statistical analysis showed that the patients were more likely to suffer from acute ischemic stroke within 1 year after the diagnosis of lung cancer (41 cases, 80.39%).

CONCLUSIONS

Hypercoagulability and acute multiple brain infarcts were more common in patients with LCA-AIS, and hypoproteinemia and hyponatremia were more likely to occur in these patients, leading to worse prognosis. Patients were most likely to have a stroke within 1 year after the diagnosis of lung cancer.

Early recurrence of ischemic stroke in patients receiving endovascular thrombectomy

BACKGROUND/PURPOSE

Endovascular thrombectomy (EVT) is effective in treating acute ischemic stroke associated with large vessel occlusion. Early recurrence of ischemic stroke (ERIS) after EVT, however, is a devastating event and could worsen the condition of patient. Current study aimed to investigate the prevalence and risk factors of ERIS after EVT.

METHODS

The medical records of all patients receiving EVT at a single medical center were reviewed and analyzed. ERIS was defined as presentation of newly developed neurological deficits in previously recanalized vascular territory or another vascular territory that was not initially involved within 30 days of the index stroke.

RESULTS

From January 2015 to September 2018, a total of 200 patients (71.6 ± 12.3 years, male 49%) had received EVT and 17 patients (8.5%) developed ERIS. Presence of valvular heart disease was the only clinical factor associated with ERIS (OR: 4.26, 95% CI: 1.16-17.7). Patients with ERIS had significantly worse modified Rankin scale at 3 months (common OR: 3.11, 95% CI: 1.18-8.73) and were independently associated with mortality (OR: 7.73, 95% CI: 2.00-30.6). Ten of 17 patients with ERIS had received repeated EVT and all achieved good recanalization without procedure-related complications or symptomatic intracerebral hemorrhage.

CONCLUSION

ERIS in patients receiving EVT was not rare, especially in those with valvular heart disease, and was associated with worse outcome. Nevertheless, they could be safely treated by repeated EVT.

An autopsy case of Trousseau's syndrome with tumor thrombosis in unknown primary squamous cell carcinoma of the head and neck

Trousseau's syndrome (TS) and tumor thrombosis (TT) are known as cancer-associated thrombosis with poor prognosis. TS is extremely rare in patients with squamous cell carcinoma. In this study, we report an unknown primary squamous cell carcinoma of the head and neck (SCCHN) patient with TS and TT in pulmonary artery definitely diagnosed by autopsy. A 73-year-old man had a past surgical history for unknown primary SCCHN and lung metastases. Three years after the initial surgery, the patient had multiple cerebral infarction, deep venous thrombosis in the legs and mediastinum metastases. Our diagnosis was TS and treatment with chemotherapy and unfractionated molecular heparin started. It could help control the hypercoagulative state and cancer progression, but finally, he died from progressive disease (mediastinum metastases and pulmonary embolism) five years after the initial surgery. An autopsy revealed multiple metastases and thrombosis in the pulmonary artery with squamous cell carcinoma microscopically. Although there is no established treatment for managing TS, intensive therapy such as a combination of chemotherapy and anticoagulant therapy can be effective in improving hypercoagulation therapy. In addition, an autopsy should be considered for patients with thrombosis to distinguish between TS and TT.

Trousseau Syndrome Related Cerebral Infarction: Clinical Manifestations, Laboratory Findings and Radiological Features

PURPOSE

We summarized the clinical manifestations, laboratory data, and brain MRI of patients with Trousseau syndrome related cerebral infarction and compared them to patients with other types of cerebral infarction. Through our present research, we hope to aid the neurologists in recognizing and diagnosing this syndrome.

METHODS

A total of 31 patients at our institution were identified with cerebral infarction resulting from Trousseau syndrome. We have also selected the 180 patients who have suffered from cerebral infarction as control groups and these patients were distributed to large-artery atherosclerosis group; cardio-embolism group; small-artery occlusion group, according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. The clinical data and neuroimage of these patients were collected.

RESULTS

All our 31 cancer patients were confirmed by pathological biopsy to be adenocarcinomas and the most common cancers are gastric and lung cancers. Patients with Trousseau syndrome exhibited high serum carbohydrate antigen CEA, CA 125 and CA 199 levels. Compared to patients with other types of cerebral infarction, patients with Trousseau syndrome had an increased severity and worse prognosis. Besides, patients had the highest mean level of plasma D-dimer. We also found multiple lesions in multiple vascular territories was the most frequent type of DWI patterns in patients of Trousseau syndrome.

CONCLUSIONS

Trousseau syndrome can progress rapidly and become life-threatening. For patients who developed unexplained cerebral infarction involving multiple arterial territories, with elevated plasma D-dimer and cancer antigens, Trousseau syndrome should always be considered.

Acute Neurological Complications of Brain Tumors and Immune Therapies, a Guideline for the Neuro-hospitalist

PURPOSE OF REVIEW

Patients with brain tumors presenting to the emergency room with acute neurologic complications may warrant urgent investigations and emergent management. As the neuro-hospitalist will likely encounter this complex patient population, an understanding of the acute neurologic issues will have value.

RECENT FINDINGS

We discuss updated information and management regarding various acute neurologic complications among neuro-oncology patients and neurologic complications of immunotherapy. Understanding of the acute neurologic complications associated with central nervous system tumors and with common contemporary cancer treatments will facilitate the neuro-hospitalist management of these patient populations. While there are aspects analogous to the diagnosis and management in the non-oncologic population, a number of unique features discussed in this review should be considered.

A Case of Trousseau's Syndrome Accompanying Ovarian Cancer with Widespread Thromboembolisms

The patient was a 41-year-old woman, gravida 0. She had no notable medical history. Laparoscopic right salpingo-oophorectomy and left cystectomy were performed for bilateral ovarian endometriomas, which were both pathologically diagnosed as benign. Six months later, she presented with left lower abdominal pain and expressive aphasia. Examination revealed multiple cerebral infarctions and pulmonary embolism. The patient was diagnosed with Trousseau's syndrome secondary to ovarian cancer, and anticoagulant therapy was initiated. Despite treatment, she developed visual field loss due to occlusion of the left retinal artery; dizziness due to cerebellar infarction and myocardial infarction; and right hemiplegia due to new cerebral infarction. She received chemotherapy (two courses of paclitaxel and carboplatin), which did not improve her condition, and died two months after onset. An autopsy revealed that her left ovary was enlarged to a size of 12 cm and an endometrioid carcinoma G2 was identified. Ovarian cancer had spread throughout the abdominal cavity, and a large amount of pleural and ascites fluid was present. Multiple thrombi were found in bilateral pulmonary arteries and bilateral common iliac veins. There was a 2.5 cm thrombus in the left ventricle apex, and the anterior descending branch was obstructed by thrombus with recanalization.

Ability of the number of territories involved on DWI-MRI to predict occult systemic malignancy in cryptogenic stroke patients

BACKGROUND

Lesions in multiple arterial territories is one of the typical features of malignancy patients with cryptogenic stroke. Hence, if patients with cryptogenic stroke display such feature, occult cancer could be predicted. The study aimed to analyze the predictive ability of the number of territories involved on DWI-MRI for occult systemic malignancy (OSM) in patients with cryptogenic stroke.

METHODS

We enrolled patients with cryptogenic stroke without a diagnosis of malignancy at stroke onset between January 2013 and November 2018. Clinical variables were analyzed between cryptogenic stroke patients with and without OSM through univariate and multiple logistic regression analyses. Points for OSM were generated by β-coefficients. The sensitivity and specificity of the risk score were assessed by the area under the receiver operating characteristic curve (AUROC). The cutoff value for predicting OSM was determined by the maximum Youden index.

RESULTS

Among 108 cyptogenic stroke patients, compared to patients without OSM (n = 96), patients with OSM (n = 12) had a lower nutrition status (P = 0.031), higher plasma D-dimer levels (P < 0.001) and more territories involved on DWI-MRI (P < 0.001). Multiple logistic regression analysis revealed that plasma D-dimer levels (OR, 3.54; 95% Cl, 1.62-7.76; P = 0.002) and the number of territories involved (OR, 4.45; 95% CI, 1.25-15.80; P = 0.021) independently predicted OSM. The predictive score system built upon the number of territories showed good discrimination with an AUROC of 0.84 (95% CI, 0.71-0.96). The cutoff value was 2 with a maximum Youden's index of 0.56, which means that patients with more than one territory involved on DWI-MRI may need extensive screening for OSM.

CONCLUSIONS

The number of territories involved on DWI-MRI was a valid predictor for OSM in cryptogenic stroke patients who need to undergo further evaluations .

Rivaroxaban versus aspirin for secondary prevention of ischaemic stroke in patients with cancer: a subgroup analysis of the NAVIGATE ESUS randomized trial

BACKGROUND AND PURPOSE

Cancer is a frequent finding in ischaemic stroke patients. The frequency of cancer amongst participants in the NAVIGATE ESUS randomized trial and the distribution of outcome events during treatment with aspirin and rivaroxaban were investigated.

METHODS

Trial participation required a recent embolic stroke of undetermined source. Patients' history of cancer was recorded at the time of study entry. During a mean follow-up of 11 months, the effects of aspirin and rivaroxaban treatment on recurrent ischaemic stroke, major bleeding and all-cause mortality were compared between patients with cancer and patients without cancer.

RESULTS

Amongst 7213 randomized patients, 543 (7.5%) had cancer. Of all patients, 3609 were randomized to rivaroxaban [254 (7.0%) with cancer] and 3604 patients to aspirin [289 (8.0%) with cancer]. The annual rate of recurrent ischaemic stroke was 4.5% in non-cancer patients in the rivaroxaban arm and 4.6% in the aspirin arm [hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.78-1.24]. In cancer patients, the rate of recurrent ischaemic stroke was 7.7% in the rivaroxaban arm and 5.4% in the aspirin arm (HR 1.43, 95% CI 0.71-2.87). Amongst cancer patients, the annual rate of major bleeds was non-significantly higher for rivaroxaban than aspirin (2.9% vs. 1.1%; HR 2.57, 95% CI 0.67-9.96; P for interaction 0.95). All-cause mortality was similar in both groups.

CONCLUSIONS

Our exploratory analyses show that patients with embolic stroke of undetermined source and a history of cancer had similar rates of recurrent ischaemic strokes and all-cause mortality during aspirin and rivaroxaban treatments and that aspirin appeared safer than rivaroxaban in cancer patients regarding major bleeds. www.clinicaltrials.gov (NCT02313909).

Diffusion-weighted imaging-documented bilateral small embolic stroke involving multiple vascular territories may indicate occult cancer: A retrospective case series and a brief review of the literature

Diffusion-weighted imaging (DWI) MRI is very sensitive for detecting small embolic brain infarctions. Stroke as the first manifestation of cancer is extremely rare. We performed a retrospective study to identify the clinical and DWI features of patients with acute ischemic stroke as the first manifestation of occult cancer. A total of five patients in our hospital from January 2017 to May 2019 were analyzed. We also reviewed the literature and seven case series (16 patients) were included. Most of these patients were aged in their sixties and lung cancer was the most common type of occult cancer. Patients showed various presentations of ischemic stroke. All of the patients showed small multiple lesions on DWI that involved mostly the anterior or both anterior and posterior territories. The lesions were mostly in both the supratentorium and infratentorium, with the mechanisms of embolic and watershed infarcts. These features were useful for identifying the causes of embolic stroke. Therefore, patients with small bilateral embolic stroke, especially those involved in multiple vascular territories, should be examined for concealed malignancy.

Stroke Exacerbates Cancer Progression by Upregulating LCN2 in PMN-MDSC

Acute ischemic stroke (AIS) is common in patients with cancer, and mounting clinical evidence suggests that it may shorten the survival of cancer patients. But how stroke affects the progression of cancer remains unclear. We inoculated B16 tumor cells (2 × 10⁵) subcutaneously before distal middle cerebral artery occlusion (dMCAO) or sham surgery in C57BL/6 mice and found that compared to sham operated mice, dMCAO mice developed significantly increased tumor volume and were accompanied by lower survival rate. To explore the underlying mechanism, we performed RNA-sequencing analysis of the tumor tissue from mice with or without stroke and found prominent upregulation of lipocalin 2 (LCN2) in the tumor from stroke mice compared to those from sham mice. Using quantitative reverse transcription-PCR, we confirmed increased mRNA expression of LCN2 as well as anti-inflammatory cytokines-Arg1, IL-10, and decreased mRNA level of pro-inflammatory cytokines-IL-6, IL-23 in the tumor of cancer-bearing stroke mice. Both immunofluorescence staining and flow cytometry analysis revealed that increased expression of LCN2 was mainly derived from the polymorphonuclear myeloid derived suppressor cells (PMN-MDSCs) in the tumor. We also found that stroke reduced the PMN-MDSCs in the peripheral blood, but increased PMN-MDSCs in the tumor of the cancer-bearing mice after stroke. In conclusion, cerebral ischemic stroke may exacerbate cancer progression by increasing LCN2 expression in PMN-MDSCs, which turns out to be a promising therapeutic target to suppress cancer progression after ischemic stroke.

Seizures in patients with cancer

Seizures are common in patients with cancer and either result from brain lesions, paraneoplastic syndromes, and complications of cancer treatment or are provoked by systemic illness (metabolic derangements, infections). Evaluation should include a tailored history, neurologic examination, laboratory studies, neuroimaging, and electroencephalogram. In unprovoked seizures, antiepileptic drug (AED) treatment is required, and a nonenzyme-inducing AED is preferred. Treatment of the underlying cancer with surgery, chemotherapy, and radiation therapy also can help reduce seizures. Benzodiazepines are useful in the treatment of both provoked seizures and breakthrough epileptic seizures and as first-line treatment for status epilepticus. Counseling for safety is an important component in the care of a patient with cancer who has seizures. Good seizure management can be challenging but significantly improves the quality of life during all phases of care, including end-of-life care.

[TROUSSEAU'S SYNDROME ACCOMPANIED BY ADVANCED PROSTATE CANCER THAT DEVELOPED ISCHEMIC STROKE; A CASE REPORT]

Trousseau's syndrome is known as a thromboembolic disorder due to hypercoagulation accompanied with advanced cancer. A 67-year-old man presented with disequilibrium and back pain, and magnetic resonance imaging of his brain indicated multiple cerebral infarctions at the acute stage. A computed tomography scan showed enlargement of multiple paraaortic lymph nodes. From these findings, we suspected that this patient had Trousseau's syndrome. The patient started anticoagulant treatment involving constant infusion with heparin Na. We also examined the origin of enlarged multiple paraaortic lymph nodes by investigating the tumor markers, which showed that the prostate specific antigen value (PSA) was extremely high. We conducted a prostatic biopsy and the pathological findings showed prostate cancer. The Combined Androgen Blockade (CAB) therapy was effective in reducing PSA value and shrinkage of the paraaortic lymph nodes. After the blood coagulation ability was improved to a normal state, we changed the anticoagulant treatment to subcutaneous injection of heparin Ca. There was no recurrence of cerebral infarction and no regrowth of prostate cancer 6 months after CAB therapy. Trousseau's syndrome is known as a poor prognosis syndrome because there is no effective therapy for the advanced stage of the accompanying cancer. However, CAB therapy is effective for advanced prostate cancer and long-term prognosis is expected. Starting anticoagulant treatment at the acute stage and maintaining anticoagulant treatment at the chronic stage are important in the treatment of Trousseau's syndrome accompanied with prostate cancer.

Utility of a scoring system for differentiating cancer-associated stroke from cryptogenic stroke in patients with cancer

BACKGROUND

The commonest type of ischemic cerebral stroke in patients with cancer is cryptogenic stroke (CRS), the majority of which are considered cancer-associated strokes (CAS) caused by multiple microemboli associated with hypercoagulation, known as Trousseau syndrome. However, detection of microemboli and diagnosing CAS is difficult. We have therefore developed a scoring system for diagnosing CAS.

METHODS

We retrospectively examined data of patients with cancer and stroke between 2006 and 2017. We identified risk factors for CRS, assigned them one or two points, and calculated total scores (Trousseau score) for each patient. We used overall survival after stroke (OSs) to validate the utility of the system.

RESULTS

In 181 consecutive strokes, CRS was the commonest type (43.6%) and had a short OSs (median 56 days). We identified the following five risks for CRS: high D-dimer concentration (≥ 10.0 μg/mL) and lesions in multiple territories (two points each); and active cancer, low platelet count (150,000/μL>) and female sex (one point each). Trousseau score ≥ 3 indicated CAS (50.3%), which had a median OSs of 50 days. Only CAS (hazard ratio 3.44 [2.34-5.10], P < 0.0001) and poor performance status (3 or 4) (2.27 [1.50-3.39], P = 0.0002) were risk factors for OSs; CRS was not. OSs of patients with non-CAS/CRS was significantly longer than that of those with CAS/CRS (404.5 days vs. 47 days, P = 0.0114), whereas OSs of CAS/non-CRS was much shorter than that of non-CAS/non-CRS (53 days vs. 547 days, P < 0.0001).

CONCLUSION

Trousseau scores simply and clearly identify CAS.

Risk of ischemic stroke in patients with prostate cancer receiving androgen deprivation therapy in Taiwan

Background

Androgen deprivation therapy (ADT) in the treatment of prostate cancer may be associated with an increased risk of thromboembolic disease. The aim of our study was to investigate the association of ADT in the treatment of prostate cancer with ischemic stroke risk.

Methods

We identified individuals older than 20 years of age who were newly diagnosed with prostate cancer between January 1, 2005, and December 31, 2012. Patients who experienced ischemic stroke or transient ischemic stroke before the index date were excluded. Patients who received at least one prescription for ADT within 6 months were defined as the ADT user group. Patients who did not receive at least one prescription for ADT within 6 months were defined as the ADT nonuser group. The patients were followed until the first occurrence of one of the primary outcome measures (ischemic stroke or death) or until December 31, 2013. The primary composite outcome was the time to any cause of death or ischemic stroke.

Results

There was no significant difference in the primary composite outcomes in the prostate cancer patients between the ADT user and nonuser groups. Prostate cancer patients who received ADT had a higher mortality rate than those who were not treated with ADT, and the adjusted hazard ratio was 1.907 (95% confidence interval: 1.278–2.844; P = 0.0016) after adjusting for age, comorbidities and comedication use.

Conclusion

ADT in the treatment of prostate cancer may not be associated with an increased risk of ischemic stroke. The differences in thromboembolic effects in cardiovascular disease and ischemic stroke secondary to ADT should be further discussed and evaluated prospectively.

Incidence, Management, Prevention and Outcome of Post-Operative Atrial Fibrillation in Thoracic Surgical Oncology

Atrial fibrillation (AF) is a common supraventricular arrhythmia, a recognized risk factor for ischemic stroke, as a potential driver for heart failure (HF). Cancer patients have an increased risk for AF, even not including any cancer-specific treatment, as surgery or chemotherapy. The mechanism is multifactorial, with inflammation and changes in autonomic tone as critical actors. Commonly, AF is a recurrent complication of the post-operative period in cancer surgery (especially thoracic). Recent papers confirmed a significant incidence of post-operative (non-cardiac surgery) AF (PAF), partially mitigated by the use of prophylactic (rate o rhythm control) treatments. A relevant difference, in terms of mean hospitalization time, emerges between patients developing PAF and those who do not, while long term impact remains a matter of debate, due to several potential confounding factors. Besides clinical predictors, structural (i.e., echocardiographic) and bio-humoral findings may help in risk prediction tasks. In this respect, pre-operative natriuretic peptides (NPs) concentrations are nowadays recognized as significant independent predictors of perioperative cardiovascular complications (including PAF), while elevated post-operative levels may further enhance risk stratification. The aim of the present paper is to trace the state of the art in terms of incidence, management, prevention, and outcome of PAF in the field of thoracic surgical oncology.

Clinical Characteristics and Risk Factors of Lung Cancer-Associated Acute Ischemic Stroke

Objective

To research the clinical characteristics and risk factors of lung cancer-associated acute ischemic stroke (LCA-AIS).

Methods

Patients diagnosed with LCA-AIS, simple lung cancer, and simple AIS were enrolled. The primary information, laboratory results, tumor histopathology, neurological deficits, and survival time of the patients were collected and analyzed.

Results

(1) In the LCA-AIS group, the pathology of 69.56% patients were adenocarcinoma, and the proportion of poorly differentiated patients was significantly more than that in moderately differentiated or highly differentiated. The number of stage IV lung cancer patients in the LCA-AIS group was significantly more common than in other stages. (2) 56.52% of patients with lung cancer were diagnosed before AIS, and the peak of AIS attack was 1–6 months after the diagnosis of lung cancer. (3) The independent risk factors of LCA-AIS were CYFRA-211 (OR 1.070; 95% confidence interval 1.005, 1.139; p = 0.035), TT (OR 1.275; 95% confidence interval 1.089, 1.493; p = 0.003), and Hct (OR 0.878; 95% confidence interval 0.779, 0.990; p = 0.034), making ROC curve, suggesting the area under the curve is 0.871. (4) The neurological deficit of patients in the LCA-AIS group was similar to the simple AIS group and could not be identified by the severity of neurological deficits. (5) The median survival time of LCA-AIS group patients was five months (95% confidence interval 3.796, 6.204). There were statistical differences in survival time between LCA-AIS group and simple AIS group patients (p < 0.001).

Conclusions

The interaction between lung cancer and AIS may shorten patients' life expectancy and worsen their quality of life.

Trousseau's syndrome associated with pulmonary pleomorphic carcinoma exhibiting aggressive features: A case report

Trousseau's syndrome is characterized as an unexpected, cancer-related thrombotic event, such as a cerebral infarction or a deep vein thrombosis/pulmonary embolism. We describe the first reported case of Trousseau's syndrome with pulmonary pleomorphic carcinoma and aggressive features. A 74 year-old man presenting with a pulmonary mass, which was identified as pleomorphic carcinoma with extensive lymph node involvement, in the left lower lobe, underwent a left lower lobectomy. Immunohistochemical analysis revealed that neoplastic cells exhibited an extensive expression of tissue factors with a mucin-producing adenocarcinoma component. Three months postoperatively, diffuse infiltration rapidly appeared in the left lung, which was identified as lymphangitic carcinomatosis via bronchoscopy. Prior to treatment for cancer recurrence, the patient presented with a left hemiplegia due to a cerebral infarction via multiple thromboses, with no evidence of atherosclerotic or cardiogenic thrombi. Elevated D-dimer and carbohydrate antigen 125 levels and the presence of a fibrin thrombus retrieved from the occluded vessel suggested Trousseau's syndrome as the etiology of the brain infarction. A hypercoagulable state associated with the aggressive recurrence of pulmonary pleomorphic carcinoma, accompanied by cancer cell production of mucin and tissue factors may be a potential mechanism for cancer-related thrombosis.

Stroke among cancer patients

We identify cancer patients at highest risk of fatal stroke. This is a population-based study using nationally representative data from the Surveillance, Epidemiology, and End Results program, 1992-2015. Among 7,529,481 cancer patients, 80,513 died of fatal stroke (with 262,461 person-years at risk); the rate of fatal stroke was 21.64 per 100,000-person years, and the standardized mortality ratio (SMR) of fatal stroke was 2.17 (95% CI, 2.15, 2.19). Patients with cancer of the prostate, breast, and colorectum contribute to the plurality of cancer patients dying of fatal stroke. Brain and gastrointestinal cancer patients had the highest SMRs (>2-5) through the follow up period. Among those diagnosed at <40 years of age, the plurality of strokes occurs in patients treated for brain tumors and lymphomas; if >40, from cancers of the prostate, breast, and colorectum. For almost all cancers survivors, the risk of stroke increases with time.

Prevalence and Impact of Venous and Arterial Thromboembolism in Patients With Embolic Stroke of Undetermined Source With or Without Active Cancer

Background

An increased risk of acute ischemic stroke is recognized among patients with cancer. However, the mechanism behind cancer‐related stroke is unclear. In this study, we determined the presence of associated venous thromboembolism and arterial thromboembolism and their clinical impact on patients with cancer‐related stroke.

Methods and Results

Patients with embolic stroke of undetermined source with or without cancer were evaluated for venous thromboembolism (deep vein thrombosis [DVT] and/or pulmonary embolism) and arterial thromboembolism by using Doppler sonography to determine the presence of lower‐extremity DVT and the microembolic signal of the symptomatic cerebral circulation, respectively. Infarct volume was determined by diffusion‐weighted magnetic resonance imaging. The multivariable linear regression and Cox proportional hazard analysis were used to investigate the effect of DVT and microembolic signal on infarct volume and 1‐year survival, respectively. Of 142 screened patients, 118 were included (37 with, 81 without cancer). Those with cancer had a higher prevalence of DVT or microembolic signal than did the noncancer group (62.2% versus 19.8%; P<0.001). Among patients with cancer‐related stroke, DVT was associated with a greater infarct volume in magnetic resonance imaging (beta, 13.14; 95% CI, 1.62–24.66; P=0.028). Presence of DVT (hazard ratio, 16.79; 95% CI, 2.05–137.75; P=0.009) and microembolic signal (hazard ratio, 8.16; 95% CI, 1.36–48.85; P=0.022) were independent predictors of poor 1‐year survival.

Conclusions

Patients with cancer‐associated embolic stroke of undetermined source have an elevated risk of associated venous thromboembolism and arterial thromboembolism, both of which have a significant negative impact on 1‐year survival. The results of this study may enhance our understanding of cancer‐associated stroke and improve risk stratification of patients with this disease.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/.Unique identifier: NCT02212496

Short-Term Outcome of Ischemic Stroke Patients With Systemic Malignancy

Background and Purpose- Recent guidelines have suggested the potential benefit of intravenous thrombolysis in stroke patients with systemic malignancy who have a reasonable life expectancy of >6 months. However, it is difficult to determine which patients with cancer will have a life expectancy of >6 months. Therefore, we identified the factors associated with 6-month mortality in patients with acute ischemic stroke and systemic malignancy. Methods- Consecutive stroke patients with systemic malignancy were retrospectively analyzed. We classified the patients into 3 groups: the nonactive cancer, active nonmetastatic cancer, and metastatic cancer groups. We compared the baseline characteristics and 6-month survival rates. Results- Of the 468 ischemic stroke patients with systemic malignancy during an 8-year period, 223 patients had nonactive cancer, 105 patients had active nonmetastatic cancer, and 140 patients had metastasis. During the 6-month follow-up, 122 patients (26.1%) died (nonactive cancer group [7.2%, 16/223], active nonmetastatic cancer group [11.4%, 12/105], and metastatic cancer group [67.1%, 94/140]). Multivariate Cox regression analysis revealed that the presence of metastasis (hazard ratio, 4.527; 95% CI, 2.175-9.422) was independently associated with 6-month mortality. However, the active nonmetastatic cancer group exhibited similar 6-month mortality to the nonactive cancer group (hazard ratio, 0.711; 95% CI, 0.282-1.795). Gastric/esophageal cancer and pancreatic cancer were also independently associated with 6-month mortality (hazard ratio, 2.068 and 2.389, respectively). Conclusions- In stroke patients with active cancer, the presence of metastasis and the cancer type were crucial factors associated with 6-month mortality.

Cancer and Cerebrovascular Disease

PURPOSE OF REVIEW

To review the latest information about the interactions between cancer and cerebrovascular disease.

RECENT FINDINGS

Additional data support the finding that both ischemic and hemorrhagic stroke are important complications of cancer or its treatment. Reperfusion therapy is being given successfully to patients with stroke complicating cancer. Hemorrhagic stroke may occur with metastatic disease to the brain, coagulopathies from cancer, in particular leukemia, or as complications of chemotherapy. Ischemic stroke also may be a complication of metastatic disease with local invasion of vessels, a pro-thrombotic disorder such as non-bacterial thrombotic endocarditis (NBTE) or disseminated intravascular coagulation (DIC), or secondary to chemotherapy. Stroke also is a potential consequence of radiation therapy to the head and neck. Venous sinus thrombosis may develop with hematologic malignancies or chemotherapy. Although many patients will have a history of cancer at the time of stroke, a cerebrovascular event may be the initial manifestation of a malignancy.

Cancer prevalence higher in stroke patients than in the general population: the Dutch String-of-Pearls Institute (PSI) Stroke study

Background and purpose

The aim of this study was to assess the prevalence of cancer and its characteristics in patients with ischemic stroke and to compare this with cancer prevalence in the general population.

Methods

This was a multicenter cohort study with 2736 patients presenting with ischemic stroke or transient ischemic attack. The prevalence of cancer was assessed by interview and verified by reviewing all medical records. In stroke patients with a history of cancer, we studied the subtype of cancer and its treatment characteristics. We used the national database of The Netherlands Cancer Registry to calculate population‐based age and sex cancer standardized prevalence ratios (SPRs) for patients with ischemic stroke.

Results

Cancer prevalence in ischemic stroke patients was 12%, corresponding to an SPR of 1.2 [95% confidence interval (CI), 1.0–1.3]. Increased SPRs were observed for cancer of the central nervous system (SPR, 18.2; 95% CI, 9.0–27.4), head and neck (SPR, 3.4; 95% CI, 2.3–4.6), lower respiratory tract (SPR, 2.4; 95% CI, 1.5–3.3) and urinary tract (SPR, 2.1; 95% CI, 1.4–2.9), but not for other cancer types. Cardiovascular risk factors, stroke etiology, treatment and outcome were not different between patients with or without a history of cancer.

Conclusions

In stroke patients, the prevalence of cancer, most prominently cancer of the central nervous system, head and neck, lower respiratory and urinary tract, was higher than in the general population. Medical treatment for the prevention of stroke in cancer survivors deserves further study.

Clinical and Imaging Characteristics of Malignant Tumor Concurrent with Stroke

Objectives: The present study aimed to retrospectively compare the clinical and imaging characteristics and laboratory data of patients with malignant tumor concurrent with acute ischemic stroke (IS) and patients with cerebral infarction only, and to analyze the potential related risk factors. Method: A total of 126 patients with acute cerebral infarction concurrent with malignant tumor were collected and assigned to the malignant tumor group. In addition, 120 patients hospitalized for routine acute IS during the same period were randomly selected as the control group. Demographic data and common risk factors of cerebrovascular disease, laboratory data, and imaging characteristics in these two groups were compared. Results: In the malignant tumor group, the age of onset was relatively low, and the National Institutes of Health Stroke Scale score, 90 d recurrence rate, and fatality rate were higher than for those in the control group (p < 0.05). However, most patients had no traditional risk factors of stroke. Biochemical results revealed that the peripheral hemoglobin of patients with malignant tumor and cerebral infarction was lower than for those in the control group (p < 0.05). Furthermore, the levels of D-dimer, fibrinogen, tumor markers CA125, CA199, and carcinoembryonic antigen were significantly elevated, and the difference was statistically significant (p < 0.05). Magnetic resonance imaging results revealed that multiple intracranial infarcts were more common in patients in the malignant tumor group, and the difference was statistically significant compared with patients with cerebral infarction only (p < 0.05). Conclusion: Patients with cancer and IS had fewer traditional stroke risk factors but more anemia as well as higher D-dimer level, tumor marker rate, short-term mortality, and stroke recurrence rate. Furthermore, lower age of onset and other characteristics, including multiple intracranial infarcts, can be regarded as important characteristics of such patients.

Cancer-associated cerebral infarction during direct oral anticoagulant treatment in cancer patients: a case series

The effect of direct oral anticoagulants (DOACs) on cancer-associated cerebral infarction (CI) is unclear. We present the clinical course of 20 consecutive patients with cancer-associated CI that developed during treatment with DOACs. The incidence rate of cancer-associated CI during the treatment with DOACs was 3.4%. The median modified Rankin scale (mRS) and Karnofsky performance status (KPS) after CI were 5 and 30, respectively. The median survival time after CI was 1 month. In the group in which the thrombus due to venous thromboembolism (VTE) was reduced before CI, the median mRS, KPS, and prognosis after CI were significantly better than in those of the group with unchanged thrombus. Cancer-associated CI also developed in patients taking DOACs and those who did not show VTE recurrence. When the VTE thrombus decreased or disappeared with DOAC treatment, the clinical course after cancer-associated CI was improved.

Link between prostate cancer diagnosis and stroke in the United States during 2007-2017

Introduction

The main purpose of this work is to study prostate cancer and stroke in the United States during the years 2007-2017 and to find not only statistically significant predictors for cancer, but also a possible association between prostate cancer and stroke.

Material and methods

The statistical methods used to derive the results of this work are χ² test and one-way analysis of variance (ANOVA), in order to check the statistical significance of prostate cancer in relation to socio-economic factors of patients. In addition, a multivariate logistic regression analysis was used with the odds ratio (OR) to find statistically significant prognostic factors for both prostate cancer and stroke.

Results

According to multiple logistic regression analysis, males who are unemployed but have worked previously have 16 times higher risk of developing prostate cancer, while widowed men have five times higher risk for the occurrence of this type of cancer. In addition, marital status and employment proved to be also prognostic risk factors for stroke.

Conclusions

Our results describe for the first time the importance of deprivation (of work and partner) as a primary prognostic risk factor for cancer. Moreover, the same factor proved to be the primary prognostic risk factor for stroke as well as for prostate cancer, a fact that implies a possible link between cancer and stroke.

Stroke Rate Increases Around the Time of Cancer Diagnosis

Objective: To test whether strokes increase around the time of cancer diagnosis, we comprehensively examined the correlations of cancer and stroke by employing a population-based cohort study design. Methods: One million people insured under the Taiwan's National Health Insurance program in 2005 were randomly sampled to create the study's dataset. According to the presence of cancer and/or stroke, patients were separated into cancer and stroke, cancer-only, and stroke-only groups. Diagnoses of cancer, stroke, and comorbidities were defined according to ICD9-CM codes. Cancer and non-cancer populations were matched by age at cancer diagnosis, gender, and stroke risk factors, and each patient with cancer was matched with two non-cancer controls nested in the same year of cancer diagnosis. The hazards of stroke and cumulative incidences within a year after cancer diagnosis were evaluated using Fine and Gray's subdistributional hazard model. Results: The temporal distribution of first-ever stroke in patients with both cancer and stroke was a sharpened bell shape that peaked between 0.5 years before and after cancer diagnosis. Frequencies of stroke were further adjusted by number of cancer survivors. The monthly event rate of stroke remained nested around the time of cancer diagnosis in all strokes. Brain malignancies, lung cancer, gastric cancer, prostate cancer, and leukemia patients obtained higher ratio of stroke, while breast cancer and thyroid cancer patients had low percentage of combining stroke. When compared to non-cancer matched control, the hazard of stroke within one year after cancer diagnosis was increased by cancer at a subdistributional hazard ratio of 1.72 (95% confident interval 1.48 to 2.01; p < 0.0001). Conclusions: Cancer increased the risk of stroke and stroke events were nested around the time of cancer diagnosis, occurring 0.5 years prior to cancer on average regardless of stroke type.

Cancer-associated stroke: Pathophysiology, detection and management (Review)

Numerous types of cancer have been shown to be associated with either ischemic or hemorrhagic stroke. In this review, the epidemiology and pathophysiology of stroke in cancer patients is discussed, while providing vital information on the diagnosis and management of patients with cancer and stroke. Cancer may mediate stroke pathophysiology either directly or via coagulation disorders that establish a state of hypercoagulation, as well as via infections. Cancer treatment options, such as chemotherapy, radiotherapy and surgery have all been shown to aggravate the risk of stroke as well. The clinical manifestation varies greatly depending upon the underlying cause; however, in general, cancer‑associated strokes tend to appear as multifocal in neuroimaging. Furthermore, several serum markers have been identified, such as high D‑Dimer levels and fibrin degradation products. Managing cancer patients with stroke is a delicate matter. The cancer should not be considered a contraindication in applying thrombolysis and recombinant tissue plasminogen activator (rTPA) administration, since the risk of hemorrhage in cancer patients has not been reported to be higher than that in the general population. Anticoagulation, on the contrary, should be carefully examined. Clinicians should weigh the benefits and risks of anticoagulation treatment for each patient individually; the new oral anticoagulants appear promising; however, low‑molecular‑weight heparin remains the first choice. On the whole, stroke is a serious and not a rare complication of malignancy. Clinicians should be adequately trained to handle these patients efficiently.

Relation of Venous Thromboembolism Risk to Ischemic Stroke Risk in Hospitalized Patients with Cancer

Patients with cancer are at increased risk for venous thromboembolism (VTE). However, the relationship of cancer type to the risk of arterial thrombosis in patients with high VTE risk has not been described. The goal of this study is to determine the rate of arterial thrombosis in patients with different types of solid tumors stratified by VTE risk. Using the 2012 National Inpatient Sample, we identified 373,789 hospitalizations involving patients ≥18 years associated with solid tumors, stratified by type. Data were collected on clinical characteristics, VTE (deep vein thrombosis [DVT] and pulmonary embolism [PE]), and arterial thrombosis (primary diagnosis of myocardial infarction [MI] and ischemic stroke). Subjects with solid tumors (stages I to IV) were stratified by VTE risk - high versus low. Certain solid tumor types (esophageal, lung, melanoma, ovarian, pancreatic, stomach, and uterine) were found to be associated with a higher rate of VTE compared with other cancer types (6.8% vs 3.9%, p < 0.001). Multivariate analysis applied to the high VTE risk group showed no increased risk for MI (odds ratio [OR] 0.93, p = 0.74), however, the rate of ischemic stroke was increased (OR 1.22, p < 0.001). Those in the high VTE risk group who had metastatic disease were at higher risk for arterial thrombosis (MI OR 1.35, p < 0.001, ischemic stroke OR 2.43, p < 0.001). In conclusion, different cancer types are associated with increased risk of both venous and arterial thrombosis and the risk is further increased by the presence of metastatic disease.

The Long-Term Effect of Cancer on Incident Stroke: A Nationwide Population-Based Cohort Study in Korea

Background and Purpose: Despite the recent growing interest in the cancer–stroke association, the long-term effect, and organ-specific association with stroke incidence in subjects with cancer have not been clearly defined.

Methods: Data were obtained from the Korean National Health Insurance Service National Sample Cohort database between 2002 and 2015. To investigate the effects of cancer on stroke incidence, subjects were classified into cancer and non-cancer groups based on the period after cancer diagnosis and origin organ of cancer. To minimize the effects of selection bias, we performed a propensity score matching analysis with covariates of demographic data, vascular risk factors, antithrombotics use and statin use. Incident stroke was diagnosed based on operational definition and classified into ischemic stroke and hemorrhagic stroke.

Results: Data of 20,707 subjects with cancer and 675,594 without cancer were analyzed for 7 follow-up years. The subjects with cancer had higher risk of any stroke (subdistribution hazard ratio [SHR], 1.13; 95% confidence interval [CI], 1.02–1.26; p = 0.0181) than those without cancer. Similar trend was found for ischemic stroke (SHR, 1.17; 95% CI, 1.05–1.31; p = 0.0054), but not for hemorrhagic stroke. The risk of stroke was increased in subjects with cancer in the digestive organ, respiratory and intrathoracic organ, and “others (such as breast and female and male reproductive organs)” in 3 years; however, the association disappeared thereafter except those with “others” cancer. Chemotherapy increased the risk of ischemic stroke (SHR 1.21; 95% CI, 1.03–1.41).

Conclusions: Cancer increases the risk of stroke at 3 years after the diagnosis of cancer, and the effect was maintained for 7 years. The association between cancer and stroke incidence depends on the organ from which the cancer originated and chemotherapy.

Three Territory Sign: An MRI marker of malignancy-related ischemic stroke (Trousseau syndrome)

Background

Multiple acute cerebral territory infarcts of undetermined origin are typically attributed to cardioembolism, most frequently atrial fibrillation. However, the importance of 3-territory involvement in association with malignancy is under-recognized. We sought to highlight the "Three Territory Sign" (TTS) (bilateral anterior and posterior circulation acute ischemic diffusion-weighted imaging [DWI] lesions), as a radiographic marker of stroke due to malignancy.

Methods

We conducted a single-center retrospective analysis of patients from January 2014 to January 2016, who suffered an acute ischemic stroke with MRI-DWI at our institution, yielding 64 patients with a known malignancy and 167 patients with atrial fibrillation, excluding patients with both to eliminate bias. All DWI images were reviewed for 3-, 2-, and 1-territory lesions. Chi-square test of proportion was used to test significance between the 2 groups.

Results

We found an association between the groups (malignancy vs atrial fibrillation) and the number of territory infarcts (p < 0.0001). Pairwise comparisons using the Holm p value adjustment showed no difference between 1- and 2-territory patterns (p = 0.465). However, the TTS was 6 times more likely observed within the malignancy cohort as compared to patients with atrial fibrillation (23.4% [n = 15] vs 3.5% [n = 6]) and was different from both 1-territory (p < 0.0001) and 2-territory patterns (p = 0.0032).

Conclusion

The TTS is a highly specific marker and 6 times more frequently observed in malignancy-related ischemic stroke than atrial fibrillation-related ischemic stroke. Evaluation for underlying malignancy in patients with the TTS is reasonable in patients with undetermined etiology.

Utilization rates of tissue plasminogen activator and mechanical thrombectomy in patients with acute stroke and underlying malignancy

Objective

Relatively little is known about the effect of malignancy on patient outcomes after acute ischemic stroke (AIS) or utilization rates of stroke interventions in this population. We aimed to assess the effect of underlying malignancy on outcomes and treatment of AIS at a population level.

Methods

Outcomes after AIS between patients with and without malignancy were compared using a national database of hospital reported outcomes.

Results

There were 351 institutions reporting the outcomes of 3 18 127 admissions for AIS. Of these admissions, 16 141 patients carried a pre-existing diagnosis of malignancy at the time of admission. Administration of intravenous tissue plasminogen activator (IV tPA) was less common in patients with malignancy compared with patients without malignancy (7.3% vs 10.7%; P<0.001) but there was no difference in the rate of mechanical thrombectomy (3.1% vs 3.1%; P=0.967). Mortality rates were higher among patients with malignancy (7.1% vs 3.7%; P<0.001), a relationship which persisted when analysis was restricted to patients receiving IV tPA (10.8% vs 6.1%; P<0.001) or thrombectomy (20.3% vs 13.5%; P<0.001). Rates of both IV tPA administration (2.5% vs 10.5%; P<0.001) and mechanical thrombectomy (2.1% vs 5.4%; P<0.001) were lower in patients with brain malignancy relative to patients with malignancy of non-CNS origin.

Conclusion

A diagnosis of malignancy on admission for acute stroke was associated with a higher rate of mortality. Malignancy was also associated with a lower rate of IV tPA administration but no difference in mechanical thrombectomy utilization.