Stroke in patients with cancer: Incidence and etiology

D-dimer >2.785 μg/ml and multiple infarcts ≥3 vascular territories are two characteristics of identifying cancer-associated ischemic stroke patients

BACKGROUND

The patterns and mechanisms underlying stroke in cancer patients differ from those of the conventional etiology. In this study, we further investigated the characteristics distinguishing cancer-associated ischemic stroke (CAIS) and the relationship of D-dimer value with CAIS.

METHODS

Sixty-one acute ischemic stroke patients with cancer (cancer group) and 76 stroke patients without cancer (control group) were recruited. Cerebrovascular distribution was divided into 3 circulations and 23 vascular territories, and acute multiple brain infarcts (AMBIs) were defined as discrete MRI diffusion-weighted imaging (DWI) lesions in >1 vascular territory.

RESULTS

Cancer patients had higher average D-dimer and fibrinogen degradation product values, and fewer stroke risk factors. The numbers of infarct-affected vascular territories, AMBIs, and AMBIs in multiple circulations were significantly higher in the cancer group. Receiver operating characteristic analysis showed that the cutoff value of D-dimer was 2.785 μg/ml; and above features were particularly evident in cancer patients whose D-dimer values were >2.785 μg/ml, while those with D-dimer values ≤2.785 μg/ml were similar to controls.

CONCLUSIONS

D-dimer >2.785 μg/ml may be an effective cutoff value and a sensitive index for identifying CAIS patients. AMBIs in ≥3 vascular territories and AMBIs in both the anterior and posterior circulations are two imaging characteristics of CAIS.

Clinical presentation, risk factors and outcome of central nervous system metastasis vs stroke in cancer patients

BACKGROUND AND PURPOSE

Cancer and stroke are the second and third causes of death worldwide; brain metastases (BM) occur in one third of patients with cancer, any neurologic deficit in these population always prompts the clinician to discard metastases for their presence carries a bad outcome. Both might share clinical presentation and differences in their outcome are not entirely known. The aim was to compare risk factors, clinical presentation, and outcome of cancer patients with BM vs stroke.

METHODS

A descriptive study with prospectively acquired data from a cancer referral center included patients seen at the neuro-oncologic unit from March 2011 to February 2018 with confirmed cancer who had BM or stroke.

RESULTS

Six hundred and thirteen BM patients were compared with 268 with stroke and cancer. Demographic factors, cancer type, risk factors, clinical presentation, and outcome are presented. Median overall survival in months for those with any stroke was 15 (95%confidence interval [CI] 8.6-21.4)-5 (95%CI 0.12.4) for hemorrhagic stroke and 22 (95%CI 13.4-30.6) in the ischemic group-and for those with BM 12 (95%CI 10.4-13.6). Hemorrhagic stroke commonly found in stroke patients as well as focal motor weakness, aphasia, and altered mental status. BM was more common in breast and lung cancer with headache, visual complaint, and/or vertigo.

CONCLUSION

Survival in cancer patients with BM is not that different than those with stroke, but clinical presentation and risk factors were found different.

Incidence, Risk Factors, and Outcomes of Arterial Thromboembolism in Patients with Pancreatic Cancer Following Palliative Chemotherapy

BACKGROUND

Few studies have explored the association between pancreatic cancer and arterial thromboembolism (aTE).

METHODS

A total of 838 consecutive patients receiving palliative chemotherapy for pancreatic cancer between 2010 and 2016 were retrospectively enrolled. The clinical characteristics of patients were analyzed to determine the incidence, risk factors, and survival outcome of aTE in patients with pancreatic cancer.

RESULTS

aTE occurred in 42 (5.0%) of 838 patients. Patients with aTE had a worse survival outcome than those without (5.1 months versus 7.8 months, hazard ratio 1.53, 95% confidence interval [CI]: 1.12⁻2.09). Stage IV disease, high aspartate transaminase level, and comorbidity with hypertension or atrial fibrillation were four independent predictors of aTE. A concise predictive model stratified patients into low (0⁻1 predictor), intermediate (2 predictors), and high (3⁻4 predictors) risk groups. The hazard ratios for the comparison of patients in intermediate and high risk groups with those in low risk group were 4.55 (95% CI: 2.31⁻8.98), and 13.3 (95% CI: 5.63⁻31.6), respectively.

CONCLUSION

Patients with pancreatic cancer undergoing palliative chemotherapy have an increased risk of aTE. A predictive model showed that patients presented with 3 or 4 predictors had the highest risk for developing aTE.

Subcutaneous Heparin Therapy for Patients with Cancer-Associated Stroke

BACKGROUND

Anticoagulation therapy, particularly subcutaneous heparin therapy, is recommended for cancer-associated thrombosis. However, not starting or discontinuing anticoagulation was not rare. The aim of the present study was to examine the practical issues related to anticoagulation therapy and effects of subcutaneous heparin therapy for cancer-associated stroke.

METHODS

Patients with cancer-associated stroke in our stroke center between October 2014 and August 2017 who were diagnosed as having acute ischemic stroke based on diffusion-weighted imaging were retrospectively enrolled. Baseline clinical characteristics, heparin injection, reasons for no subcutaneous heparin therapy, and clinical outcomes were collected.

RESULTS

A total of 59 patients with cancer-associated stroke (75 ± 10 years old, male 42%) were enrolled. Lung cancer was the most frequently observed cancer (n = 17, 29%), followed by gastric cancer (n = 8, 14%) and pancreatic cancer (n = 8, 14%). Of the 19 patients (32%) who underwent subcutaneous heparin therapy, it was discontinued in 9 (47%), mainly because of patients' medical conditions (deterioration of cancer or hemorrhagic complication). Ten patients with long-term subcutaneous heparin therapy did not have stroke recurrence. In contrast, among nine patients who discontinued subcutaneous heparin therapy, three (33%) had recurrence of ischemic stroke. Of the 40 patients without subcutaneous heparin therapy, the main reasons for no subcutaneous heparin therapy were the patients' medical conditions (n = 22, 55%).

CONCLUSIONS

Although subcutaneous heparin therapy was given to only one third of cancer-associated stroke patients, long-term subcutaneous heparin therapy might prevent recurrence of cancer-associated stroke.

Cancer and dementia: Two sides of the same coin?

Noncentral nervous system cancer and the brain share an interesting and complex relation, with an emerging body of evidence showing that cancer patients are at an increased risk of developing cognitive problems. In contrast, population-based studies consistently find an inverse link between cancer and dementia, that is patients with dementia having a lower risk of subsequently developing cancer, and cancer patients being less often diagnosed with dementia. Different biological processes such as inversely activated cell proliferation and survival pathways have been suggested to have an important role underlying this inverse association. However, the effect of methodological biases including surveillance or survival bias has not been completely ruled out, calling into question the inverse direction of the association between cancer and dementia. In fact, emerging evidence now suggests that cancer and dementia might share a positive association. This narrative review summarises the current literature on cancer, cognitive problems and dementia. Moreover, different strategies will be discussed to reduce the impact of potential methodological biases on the association between cancer and dementia, trying to reveal the true direction of this link.

Mitral valve nonbacterial thrombotic endocarditis: a rare multi-surgery-tolerant survivor of Trousseau's syndrome

BACKGROUND

Few previous reports have documented cases of nonbacterial thrombotic endocarditis associated with Trousseau's syndrome for which surgery proved possible for both the primary tumor and the cardiac lesion. The effectiveness of direct oral anticoagulants in patients with Trousseau's syndrome has also received scant attention.

CASE PRESENTATION

A 69-year-old man with repeated episodes of cerebral infarction was diagnosed as having nonbacterial thrombotic endocarditis after mitral valve replacement surgery. Stroke recurred preoperatively under apixaban administration. A stomach biopsy also identified gastric adenocarcinoma, and gastric surgery was performed on the 40th postoperative day. The patient was discharged from the hospital and has been free of thromboembolism under a regime of subcutaneous heparin self-injection thereafter.

CONCLUSIONS

We have reported a rare multi-surgery-tolerant survivor of Trousseau's syndrome in whom subcutaneous heparin injection was useful for preventing thromboembolic events over a long period.

Platelet count is associated with outcome in cancer patients with stroke

INTRODUCTION

Cerebrovascular disease (CVD) and cancer are among the most common causes of mortality worldwide, preceded only by ischemic heart disease (IHD). Thrombocytopenia was shown to be associated with poor outcomes in IHD and CVD in the general population. This study aimed to assess the relationship of thrombocytopenia with poor outcomes in cancer patients with CVD.

MATERIALS AND METHODS

Data on patients with concomitant CVD and cancer who were initially treated at a cancer referral center between January 2010 and December 2017 were included. Thrombocytopenia was defined as a platelet count < 150,000/mm³ during the first 24 h of CVD symptom onset. The IRB (CI/837/17) approved the review of clinical records.

RESULTS

Among 268 cancer patients with CVD included in the study, 210 met the inclusion criteria. Median overall survival of the entire cohort was 7.2 months, which was significantly shorter in males (p = 0.029) and patients with hematologic tumors (p = 0.009), hemorrhagic CVD (p < 0.001), altered mental status (p < 0.001), and thrombocytopenia (p < 0.001). Multiple regression logistic analysis revealed that thrombocytopenia (risk ratio [RR] 1.6, 95% confidence interval [CI] 1.1-2.4) and altered mental status (RR 2.7, 95% CI 1.9-4.0) remained statistically significant risk factors for mortality.

CONCLUSION

In cancer patients with CVD, thrombocytopenia at the time of CVD diagnosis and altered mental status during initial clinical evaluation were associated with higher mortality, which should be confirmed in future studies.

Changes in Serial D-Dimer Levels Predict the Prognoses of Trousseau's Syndrome Patients

Background: The development of acute multiple embolic infarctions (AMEI) resulting from cancer is known as Trousseau's syndrome (TS). At present, however, there is no good marker for predicting the prognosis of TS patients. In the present study, we evaluated the use of serial D-dimer levels as a prognostic marker for TS.

Methods: This retrospective cohort study included 1,409 consecutive acute ischemic stroke patients. We selected a group of patients with TS showing AMEI (n = 38; TS group) and a group of patients with atrial fibrillation (Af) and AMEI (n = 35; Af group) as controls. Serial D-dimer levels were measured between days 7 and 28 after stroke (sub-acute phase) in 21 patients of the TS group and 24 patients of the Af group.

Results: D-dimer levels at onset (acute phase) were significantly higher in the TS group (8.45 ± 1.79 μg/mL, n = 38) compared with the Af group (1.14 ± 0.14 μg/mL, n = 35) (p < 0.0001). In patients for whom serial D-dimer measurements were made, D-dimer levels measured at the sub-acute phase decreased to 0.48 ± 0.12 μg/mL (n = 24) in the Af group, but remained elevated in the TS group during the sub-acute phase (11.20 ± 2.77 μg/mL, n = 21) (p < 0.0001). In all TS patients in whom serial D-dimer measurements were made, D-dimer levels in 17 patients who died within 500 days (13.31 ± 3.23 μg/mL) were significantly higher than those of the four surviving patients (2.23 ± 0.38 μg/mL) (cut-off D-dimer level = 3.0 μg/mL) during this period. Moreover, serial D-dimer levels of 10 patients who died within 90 days (17.78 ± 4.60 μg/mL) were significantly higher than those of the 11 patients who survived up to 90 days (5.21 ± 2.12 μg/mL) (p < 0.05).

Conclusions: Serial D-dimer levels may be a good biomarker for TS as well as a useful predictor of the prognosis of TS patients.

Multifocal cerebral infarction as the first manifestation of occult malignancy: Case series of trousseau's syndrome and literature review

Ischemic stroke as an initial presentation of malignancy is extremely rare and the underlying etiology is often ignored. The aim of this study is to outline the clues to occult malignancy in patients presenting with cerebral infarction initially. The clinical characteristics of total 19 patients with Trousseau's Syndrome presenting with cerebral infarction initially were analyzed. Among those patients, no conventional vascular risk factors were detected in 68% (13/19) of patients, and infarction occurring in multiple vascular distributions was found in 84% (16/19). Blood test showed thrombophilia in 79% (15/19) of patients with significantly elevated D-dimer, disseminated intravascular coagulopathy (DIC) in 59% (11/19), and elevated levels of tumor makers in 47% (9/19). The prognosis of the 19 patients was poor, with 68% (13/19) of patients undergoing a relapse of stroke in short interval, and 84% (16/19) being reportedly to die in 6 months. In patients, who developed unexplained recurrent brain infarction involving multiple arterial territory, with laboratory evidence suggesting hypercoagulability (higher level of D-dimer, or DIC), Trousseau's Syndrome should be considered, and investigation for an occult malignancy was required.

Ischemic stroke in cancer patients: A review of an underappreciated pathology

Currently 1 in 10 patients with ischemic stroke have comorbid cancer, and this frequency is expected to increase with continued advances in cancer therapeutics prolonging median survival. Well known for its association with venous thrombosis, cancer has recently emerged as a significant risk factor for arterial thromboembolism, including stroke; however, the underlying mechanisms are uncertain. In addition, the optimal strategies to prevent and acutely treat stroke in cancer patients are yet to be established. This review summarizes the current evidence on ischemic stroke risk, biomarkers, pathophysiology, treatments, and prognosis in cancer patients, emphasizing knowledge gaps and the potential strategies to address them. Ann Neurol 2018;83:873-883.

Effect of Statins on Survival Following Stroke in Patients With Cancer

The objective of this study was to investigate the potential benefits of statin therapy initiation in acute stroke in patients with active cancer. This study was conducted in two parts. First, data from patients who are presented with stroke and active cancer were obtained from prospectively collected multicenter hospital-based stroke registries. Patients were classified into statin user and non-user groups; the statin group was further divided into low-potency and high-potency statin subgroups. The primary outcome was time to mortality. Second, we obtained data from the Korean National Health Information Service-National Sample Cohort (NHIS-NSC) database for external validation and analyzed the effect of statins on mortality, taking compliance into consideration. For the stroke registry cohort, statin use was independently associated with reduced mortality in a multivariable model [hazard ratio (HR) = 0.675, 95% confidence interval (CI) = 0.457–0.996]. There was no interaction between statin use and cancer characteristics, vascular risk factors, or laboratory findings. A dose-dependent relationship between statin use and survival was also demonstrated. Analysis of the NHIS-NSC database found a similar association between statin therapy and reduced mortality (adjusted HR = 0.64, 95% CI = 0.45–0.90) and this effect persisted even after controlling for the adherence of statin use (HR = 0.60, 95% CI = 0.41–0.89). Statin therapy could be associated with reduced mortality in patients with acute stroke and active cancer.

Severe Fatal Systemic Embolism Due to Non-Bacterial Thrombotic Endocarditis as the Initial Manifestation of Gastric Adenocarcinoma: Case Report

Introduction

Nonbacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, is a rare, underdiagnosed complication of cancer, in the context of a hypercoagulable state. NBTE represents a serious complication due to the high risk of embolisation from the sterile cardiac vegetations. If these are not properly diagnosed and treated, infarctions in multiple arterial territories may occur.

Case presentation

The case of a 47-year-old male is described. The patient was diagnosed with a gastric adenocarcinoma, in which the first clinical manifestation was NBTE. Subsequently, a hypercoagulability syndrome was associated with multi-organ infarctions, including stroke and eventually resulted in a fatal outcome.

Conclusions

NBTE must be considered in patients with multiple arterial infarcts with no cardiovascular risk factors, in the absence of an infectious syndrome and negative blood cultures. Cancer screening must be performed to detect the cause of the prothrombotic state.

Risk Factors, Biomarkers, Etiology, Outcome and Prognosis of Ischemic Stroke in Cancer Patients

Introduction: Cerebrovascular disease is the second most common complication in individuals with tumours. The aim of this study was to investigate risk factors, biomarkers, etiology and prognosis of ischemic stroke in cancer patients (ISCPs). Methods: The medical records of 619 consecutive patients who were admitted with acute ischemic stroke from January 2012 to November 2014 were retrospectively evaluated. The patients were divided into two groups (group 1, patients with an active cancer prior to the onset of ischemic stroke; group 2, patients without an active cancer history). The demographic data, risk factors, NIHSS scores, thrombocyte count, D-dimer, fibrinogen and C reactive protein (CRP) level at admission, modified Rankin Scale (mRS) scores in the follow-up period and location of lesions on DWI were recorded. The Mann-Whitney U test, chi-squared test and logistic regression was used for analyzing data, p<0.05 being considered statistically significant. Results: A total of 46 (7.4%) ISCPs were included. Hyperlipidemia was significantly lower in the ISCP group (p=0.001). Elevated thrombocyte counts, D-dimer, fibrinogen and CRP levels at admission, acute multiple ischemic lesions, other causes, mortality in hospital and worse outcome were significantly related to ISCP (p<0.05). On logistic regression analysis, follow up mRS>3, acute multiple ischemic lesions located in more than one vascular territory (AMIMCT) and other causes were significantly associated with ISCP (p<0.001). Conclusion: In our study, other causes, AMIMCT and mRS>3 were more common in the ISCP group. We consider that CCS could be more suitable for detecting other causes than TOAST. Biomarkers could be important in the ISCP group.

Acantholytic squamous cell carcinoma of the lung with marked lymphogenous metastases and high titers of myeloperoxidase-antineutrophil cytoplasmic antibodies: a case report

BACKGROUND

Acantholytic squamous cell carcinoma (ASQCC), histologically characterized by intercellular bridge loosening, is recognized as a rare variant of squamous cell carcinoma (SQCC). ASQCC may demonstrate a worse prognosis than conventional SQCC. Pulmonary ASQCC is particularly rare; its biological behavior and prognostic data have not been reported.

CASE PRESENTATION

We report the clinical and autopsy findings of a 71-year-old Japanese man with pulmonary ASQCC. Pulmonary lesions, suggestive of idiopathic interstitial pneumonia, were radiologically observed 3 and 6 years prior to the patient's most recent hospitalization; however, the patient did not undergo further medical examinations. Upon being discovered unconscious, the patient was admitted to our hospital. Dehydration and lower limb muscle weakness were noted, as were laboratory findings of coagulation abnormalities and renal dysfunction. Computed tomography helped confirm a 21-mm peripheral nodule in the upper left lobe of the lung, with associated swollen lymph nodes in the bilateral hilar, mediastinal, and para-aortic regions. Brain and spinal lesions, suggestive of neurological disturbances, were not found. Small cell lung carcinoma was suspected, upon admission, but high serum levels of squamous cell carcinoma antigen and cytokeratin-19 fragments were present. Therefore, advanced lung cancer, possibly SQCC, was diagnosed. The patient was treated with best supportive therapy, and died one month after admission. Hypercalcemia and high serum levels of parathyroid hormone-related protein (PTHrP) and myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) titers were observed. Progressive renal insufficiency was absent due to improved renal function subsequent to hydration. An autopsy helped confirm the left lung tumor as an ASQCC associated with pulmonary lymphangitic carcinomatosis and multiple metastases in the lungs and lymph nodes. Skin lesions suggesting malignant tumors were absent. The metastatic lesions consisted largely of acantholytic tumor cells, and the lungs showed usual interstitial pneumonia pattern; vasculitis was absent.

CONCLUSIONS

This is the first reported case of pulmonary ASQCC resulting in an aggressive clinical course, with marked lymphogenous metastases and PTHrP-associated hypercalcemia. The high serum MPO-ANCA titers were clinicopathologically insignificant, but may have been related to the pulmonary interstitial lesion. Pulmonary ASQCC represents a highly malignant subset of lung cancer.

Cancer-associated ischemic stroke: A retrospective multicentre cohort study

BACKGROUND

The association between stroke and cancer is well-known but insufficiently investigated. Aim of this multicentre retrospective cohort study was to estimate the prevalence of cancer-associated ischemic stroke, describe clinical outcomes in patients with cancer-associated ischemic stroke and investigate independent factors associated with active cancer.

METHODS

Consecutive adult patients admitted for acute ischemic stroke were included. Included patients were admitted in the Stroke Unit of the Hospital of Perugia, Italy, from March 2005 to March 2015, and in a medical unit of the Hospital of Varese, Italy, from January 2010 till December 2011. Clinical and laboratory data of patients with and without active cancer were collected. Multivariate logistic regression analysis was performed to identify independent factors associated with active cancer.

RESULTS

A total of 2209 patients admitted with acute ischemic stroke were included with a median hospital stay of 9 days (interquartile range 5.75-14). Mean age was 72.7 years (standard deviation +/- 13); 55% patients were male and 4.4% had active cancer. Factors significantly associated with the presence of active cancer were age > 65 years (odds ratio [OR] 3.34; 95% confidence interval [CI] 1.64-6.81), occurrence of venous thromboembolism [VTE] (OR 2.84; 95% CI 1.12-7.19), low-density lipoprotein (LDL) cholesterol level < 70 mg/dL (OR 1.92; 95% CI 1.06-3.47), cryptogenic stroke subtype (OR 1.93; 95% CI 1.22-3.04). Overall mortality rate during hospital stay was greater in patients with active cancer (21.5% vs. 10% P < 0.05).

CONCLUSIONS

Older age, occurrence of VTE, low LDL level, and cryptogenic stroke subtype, are independently associated with active cancer. Overall, our findings suggest a possible prevalent role of hypercoagulability in the pathogenesis of cancer-associated ischemic stroke.

Perioperative Retinal Artery Occlusion: Incidence and Risk Factors in Spinal Fusion Surgery From the US National Inpatient Sample 1998-2013

BACKGROUND

Retinal artery occlusion (RAO) is a rare but devastating complication of spinal fusion surgery. We aimed to determine its incidence and associated risk factors.

METHODS

Hospitalizations involving spinal fusion surgery were identified by searching the National Inpatient Sample, a database of hospital discharges, from 1998 to 2013. RAO cases were identified using ICD-9-CM codes. Using the STROBE guidelines, postulated risk factors were chosen based on literature review and identified using ICD-9-CM codes. Multivariate logistic models with RAO as outcome, and risk factors, race, age, admission, and surgery type evaluated associations.

RESULTS

Of an estimated 4,784,275 spine fusions in the United States from 1998 to 2013, there were 363 (CI: 291-460) instances of RAO (0.76/10,000 spine fusions, CI: 0.61-0.96). Incidence ranged from 0.35/10,000 (CI: 0.11-1.73) in 2001-2002 to 1.29 (CI: 0.85-2.08) in 2012-2013, with no significant trend over time (P = 0.39). Most strongly associated with RAO were stroke, unidentified type (odds ratio, OR: 14.33, CI: 4.54-45.28, P < 0.001), diabetic retinopathy (DR) (OR: 7.00, CI: 1.18-41.66, P = 0.032), carotid stenosis (OR: 4.94, CI: 1.22-19.94, P = 0.025), aging (OR for age 71-80 years vs 41-50 years referent: 4.07, CI: 1.69-10.84, P = 0.002), and hyperlipidemia (OR: 2.96, CI: 1.85-4.73, P < 0.001). There was an association between RAO and transforaminal lumbar interbody fusion (OR: 2.95, CI: 1.29-6.75, P = 0.010). RAO was more likely to occur with spinal surgery performed urgently or emergently compared with being done electively (OR: 0.40, CI: 0.23-0.68, P < 0.001).

CONCLUSIONS

Patient-specific associations with RAO in spinal fusion include aging, carotid stenosis, DR, hyperlipidemia, stroke, and specific types of surgery. DR may serve as an observable biomarker of heightened risk of RAO in patients undergoing spine fusion.

In-Hospital Cerebrovascular Outcomes of Patients With Atrial Fibrillation and Cancer (from the National Inpatient Sample Database)

Limited data are available regarding the impact of cancer on cerebrovascular accidents in patients with atrial fibrillation (AF). We queried the Nationwide Inpatient Survey Database to identify patients who have diagnostic code for AF. We performed a 1:1 propensity matching based on the CHA₂DS₂VASc score and other risk factors between patients with AF who had lung, breast, colon, and esophageal cancer, and those who did not (control). The final cohort included a total of 31,604 patients. The primary outcome of in-hospital cerebrovascular accidents (CVA) was lower in the cancer group than in the control group (4% vs 7%, p < 0.001), but with only a weak association (ф = -0.067). In-hospital mortality was higher in the cancer group than in the control group (18% vs 11%, p < 0.001; ф = -0.099). A subgroup analysis according to cancer type showed similar results with a weak association with lower CVA in breast cancer (4% vs 7%; ф = -0.066, p < 0.001), lung cancer (4% vs 6%; ф = -0.062, p < 0.001), colon cancer (4% vs 6%; ф = -0.062, p < 0.001), and esophageal cancer (3% vs 7%; ф = -0.095, p < 0.001) compared with the control groups. A weak association with higher in-hospital mortality was demonstrated in lung cancer (20% vs 11%; ф = -0.127, p < 0.001), colon cancer (16% vs 11%; ф = -0.076, p < 0.001), and esophageal cancer (20% vs 12%; ф = -0.111, p < 0.001) compared with the control groups, but no significant difference between breast cancer and control groups in mortality (11% vs 11%; ф = -0.002, p = 0.888). In conclusion, in patients with AF, cancer diagnosis may not add a predictive role for in-hospital CVA beyond the CHADS2VASc score.

Increased risk of brain cancer incidence in stroke patients: a clinical case series, population-based and longitudinal follow-up study

Stroke and brain cancer are two distinct diseases. However, the relationship between both diseases has rarely been examined. This study investigated the longitudinal risk for developing brain cancer in stroke patients. To study this, we first reviewed the malignant gliomas previously with or without stroke using brain magnetic resonance imaging (MRI) images and the past histories. Two ischemic stroke patients before the malignant glioma were identified and belonged to the glioblastoma mutiforme (GBM). Particularly, both GBM specimens displayed strong hypoxia-inducible factor 1α (HIF-1α) expression in immunohistochemical (IHC) staining. To elucidate the significance of this relationship, we then used a nationwide population-based cohort in Taiwan to investigate the risk for the incidence of brain cancer in patients previously with or without stroke. The incidence of all tumors in the stroke group was lower than that in the control group with an adjusted hazard ratio (HR) of 0.79 (95% confidence interval [CI]: 0.74-0.84) in both gender and age older than 60 years. But the stroke patients had higher risk of developing only brain cancer with an adjusted HR of 3.09 (95% CI: 1.80-5.30), and otherwise had lower risk of developing head and neck, digestive, respiratory, bone and skin, as well as other tumors, all with p<0.05. After stratification by gender and age, the female and aged 40-60 year old stroke patients had higher risk of developing brain cancer with an adjusted HR of 7.41 (95% CI: 3.30-16.64) and 16.34 (95% CI: 4.45-62.13), respectively, both with p<0.05. Patients with stroke, in particular female and age 40-60 years old, have an increased risk for developing brain cancer.

Prognostic Significance of Troponin Elevation for Long-Term Mortality after Ischemic Stroke

Background and Purpose

Troponin, a marker of myocardial injury, frequently increases and is related with poor outcome in ischemic stroke patients. However, the long-term outcome of this elevation remains uncertain. We, therefore, investigated the prognostic significance of troponin elevation for long-term mortality, and explored factors affecting troponin elevation after ischemic stroke.

Methods

We retrospectively analyzed the medical data of stroke patients who were admitted within 24 hours of symptom onset and underwent a serum cardiac troponin I test at admission during a five-year period. Information on mortality as the outcome was obtained from the National Death Certificate system.

Results

A total of 1,692 patients were eligible for inclusion with 33 months of median follow-up. Troponin elevation that exceeded the 99th percentile (>0.04 ng/mL) of values was detected in 166 patients (9.8%). After adjusting for baseline characteristics, troponin elevation was associated with previous ischemic heart disease and congestive heart failure, comorbid atrial fibrillation and active cancer, and increased National Institutes of Health Stroke Scale score. Patients with troponin elevation had a high risk of overall death (hazard ratio [HR] 1.83, 95% confidence interval [CI] 1.40–2.40), including stroke-related (HR 1.71, 95% CI 1.14–2.55), cardiac-related (HR 3.17, 95% CI 1.49–6.74), and cancer-related (HR 1.98, 95% CI 1.14–3.45) death than those without troponin elevation.

Conclusions

Troponin elevation in the acute stage of ischemic stroke was associated with long-term mortality, mainly due to increased stroke- and cancer-related death in the first year and cardiacrelated death in the later period.

D-dimer levels and cerebral infarction in critically ill cancer patients

BACKGROUND

D-dimer levels have been used in the diagnosis of a variety of thrombosis-related diseases. In this study, we evaluated whether measuring D-dimer levels can help to diagnose cerebral infarction (CI) in critically ill cancer patients.

METHODS

We retrospectively evaluated all cancer patients who underwent brain magnetic resonance imaging (MRI) between March 2010 and February 2014 at the medical oncology intensive care unit (ICU) of Samsung Medical Center. Brain MRI scanning was performed when CI was suspected due to acute neurological deficits. We compared D-dimer levels between patients ultimately diagnosed as having or not having CI and analyzed diffusion-weighted imaging (DWI) lesion patterns.

RESULTS

A total of 88 patients underwent brain MRI scanning due to clinical suspicion of CI; altered mental status and unilateral hemiparesis were the most common neurological deficits. CI was ultimately diagnosed in 43 (49%) patients. According to the DWI patterns, multiple arterial infarctions (40%) were more common than single arterial infarctions (9%). Cryptogenic stroke etiologies were more common (63%) than determined etiologies. There was no significant difference in D-dimer levels between patients with and without CI (P = 0.319). Although D-dimer levels were not helpful in diagnosing CI, D-dimer levels were associated with cryptogenic etiologies in critically ill cancer patients; D-dimer levels were higher in the cryptogenic etiology group than in the determined etiology group or the non-infarction group (P = 0.001). In multivariate analysis, elevated D-dimer levels (> 8.89 μg/mL) were only associated with cryptogenic stroke (adjusted OR 5.46; 95% confidence interval, 1.876-15.857).

CONCLUSIONS

Abnormal D-dimer levels may support the diagnosis of cryptogenic stroke in critically ill cancer patients.

Multiple recurrent ischaemic strokes in a patient with cancer: is there a role for the initiation of anticoagulation therapy for secondary stroke prevention?

A 52-year-old woman with a medical history of cervical and thyroid cancer, hypertension, dyslipidaemia, uncontrolled diabetes and heavy smoking was diagnosed with a new metastatic cholangiocarcinoma. While undergoing palliative chemotherapy, she developed dysarthria and left-sided weakness. Imaging studies showed multiple bilateral ischaemic strokes. On hospital days 2 and 5, she developed worsening neurological symptoms and imaging studies revealed new areas of ischaemia on respective days. Subsequent workup did not revealed a clear aetiology for the multiple ischaemic events and hypercoagulability studies were only significant for a mildly elevated serum D-dimer level. Although guidelines are unclear, full-dose anticoagulation with low molecular weight heparin was initiated given her high risk of stroke recurrence. She was discharged to acute rehabilitation but, within a month, she experienced complications of her malignant disease progression and a new pulmonary thromboembolism. The patient died soon after being discharged home with hospice care.

Cancer, atrial fibrillation, and stroke

Cancer patients appear to be at increased risk for atrial fibrillation. Although surgery and chemotherapy exacerbate this risk, this association is observed even in the absence of any cancer-specific treatment. The underlying mechanism of this is likely multifactorial, but systemic inflammation and autonomic dysregulation are hypothesized to play critical roles. Cancer and atrial fibrillation are both independent risk factors for ischemic stroke; however, it is not clear whether this translates to an increased risk of stroke in patients with both comorbidities. As such, commonly used risk stratification tools including the CHADS2 score currently do not take cancer into account as a variable and it is possible that stroke risk is underestimated in this population. There is a paucity of data regarding anticoagulant choice in cancer patients with atrial fibrillation. Vitamin K antagonists are often preferred over direct oral anticoagulants; however, this may be changing in the near future as new trials specific to this patient population emerge.

Cryptogenic Stroke: Research and Practice

BACKGROUND

Cryptogenic stroke accounts for 30% to 40% of ischemic stroke. It is essential to determine the possible culprit because this will improve secondary stroke prevention strategies.

METHODS

We performed a narrative nonsystematic review of the literature that included randomized trials, exploratory comparative studies, and case series on cryptogenic stroke.

RESULTS

There are several possible mechanisms implicated in cryptogenic stroke, including occult paroxysmal atrial fibrillation, patent foramen ovale, aortic arch atherosclerosis, atrial cardiopathy, and substenotic atherosclerosis. The heterogeneity of these mechanisms leads to differences in stroke prevention strategies among cryptogenic stroke patients.

CONCLUSIONS

A thorough diagnostic evaluation is essential to determine the pathogenesis in cryptogenic stroke. This approach, in addition to risk factor management and lifestyle modifications, will lead to improved stroke prevention strategies in patients with cryptogenic stroke. This will allow for targeted clinical trials to improve stroke prevention strategies in this patient population.

Identifying ischemic stroke associated with cancer: a multiple model derived from a case-control analysis

Ischemic stroke in patients with cancer is thought to be associated with a worse prognosis and might be the initial symptom of an unknown malignancy. However, diagnostic algorithms to reliably identify cancer-associated stroke have not been developed. In this retrospective single-centre analysis, 68 patients with ischemic stroke and an active solid malignancy were identified. Neurological assessment and outcome, cardiovascular risk factors, neuroimaging studies as well as laboratory findings were compared to 68 age- and sex-matched control subjects with ischemic stroke without diagnosis of cancer. Lung, pancreatic and renal cancer showed increased prevalences compared to those of the general population in Germany. Diagnosis of cancer was most often made within the 12 months preceding (32.4%) or during the diagnostic work-up for stroke (17.7%). Cancer-associated stroke was characterized by a more severe clinical deficit, frequent clinical deterioration (13.2 vs. 1.5%) or death (25 vs. 4.4%). Ischemic lesions often involved multiple territories (51.6 vs. 12.7%), more often with co-existing subacute and acute infarctions in imaging studies (54.8 vs. 11.1%). Patients with cancer had significantly higher levels of C-reactive protein, relative granulocytosis and serum lactate dehydrogenase activity. Using receiver operating characteristics-based multiple analysis, we developed a model using these parameters which detected cancer-associated stroke with a sensitivity of 75% and specificity of 95%. Our analysis suggests that a multiple algorithm combining the number of territories involved and laboratory signs of inflammation and cell turnover might identify patients with stroke suffering from previously unknown malignancy.

Management of neuro-oncologic emergencies

Patients with brain tumors and systemic malignancies are subject to diverse neurologic complications that require urgent evaluation and treatment. These neurologic conditions are commonly due to the tumor's direct effects on the nervous system, such as cerebral edema, increased intracranial pressure, seizures, spinal cord compression, and leptomeningeal metastases. In addition, neurologic complications can develop as a result of thrombocytopenia, coagulopathy, hyperviscosity syndromes, infection, immune-related disorders, and adverse effects of treatment. Patients may present with typical disease syndromes. However, it is not uncommon for patients to have more subtle, nonlocalizing manifestations, such as alteration of mental status, that could be attributed to other systemic, nonneurologic complications. Furthermore, neurologic complications are at times the initial manifestations of an undiagnosed malignancy. Therefore a high index of suspicion is essential for rapid assessment and management. Timely intervention may prolong survival and improve quality of life. In this chapter, we will discuss the common neuro-oncologic emergencies, including epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment.

Plasma D-dimer levels and ischaemic lesions in multiple vascular regions can predict occult cancer in patients with cryptogenic stroke

BACKGROUND AND PURPOSE

Cancer patients with cryptogenic stroke often have high plasma D-dimer levels and lesions in multiple vascular regions. Hence, if patients with cryptogenic stroke display such characteristics, occult cancer could be predicted. This study aimed to investigate the clinical characteristics of cryptogenic stroke as the first manifestation of occult cancer and to determine whether plasma D-dimer levels and lesions in multiple vascular regions can predict occult cancer in patients with cryptogenic stroke.

METHODS

Between January 2006 and October 2015, data on 1225 patients with acute ischaemic stroke were extracted from the stroke database of Osaka University Hospital. Among them, 184 patients were classified as having cryptogenic stroke, and 120 patients without a diagnosis of cancer at stroke onset were identified. Clinical variables were analyzed between cryptogenic stroke patients with and without occult cancer.

RESULTS

Among 120 cryptogenic stroke patients without a diagnosis of cancer, 12 patients had occult cancer. The body mass index, hemoglobin levels and albumin levels were lower; plasma D-dimer and high-sensitivity C-reactive protein levels were higher; and lesions in multiple vascular regions were more common in patients with than in those without occult cancer. Multiple logistic regression analysis revealed that plasma D-dimer levels (odds ratio, 3.48; 95% confidence interval, 1.68-8.33; P = 0.002) and lesions in multiple vascular regions (odds ratio, 7.40; 95% confidence interval, 1.70-39.45; P = 0.01) independently predicted occult cancer.

CONCLUSIONS

High plasma D-dimer levels and lesions in multiple vascular regions can be used to predict occult cancer in patients with cryptogenic stroke.

A case of anticoagulant treatment-resistant Trousseau syndrome controlled by treatment of the underlying lung adenocarcinoma: Utility of monitoring D-dimer levels

We report herein a 70-year-old woman, with repeated thromboembolic events, including three cerebral embolisms and two venous thromboembolisms, despite adequate anticoagulant therapy. Trousseau syndrome was suspected, and she was diagnosed as having lung adenocarcinoma. Chemoradiotherapy was started, achieving improvements in the lung cancer, and thrombosis was also brought under control. Ten months later, the lung cancer relapsed, and second-line chemotherapy was performed. D-dimer levels, which had normalized after the first-line therapy, increased together with the relapse, but became negative again following the chemotherapy. In general, the prognosis of Trousseau syndrome is diverse. However, in this case, the course was good following the second lung cancer therapy: D-dimer levels did not increase, and there were no recurrences of thromboembolism. This experience reminds us the prognosis is most affected by whether the underlying disease is being effectively treated, and suggests that for Trousseau syndrome, despite adequate anticoagulant therapy, elevation of D-dimer levels should consider the recurrent cancer. <Learning objective: We report herein a case with repeated thromboembolic events as a result of Trousseau syndrome due to lung cancer. Chemotherapy achieved improvements, but the cancer relapsed and second-line chemotherapy was done. D-dimer levels, which had normalized, increased with the relapse before again becoming negative. This experience reminds us that prognosis is affected by treating underlying disease and suggests that elevation of D-dimer levels should consider the cancer recurrence.>.

Vascular complications in glioma patients

Vascular complications in patients with glioma most commonly include venous and arterial thromboembolism; however, treatment-induced vasculopathies are also problematic, especially in long-term survivors. The interactions between treatment such as radiation and chemotherapy, the coagulation cascade, endothelium, and regulators of angiogenesis are complex, drive glioma growth and invasion, and create common management problems in the clinic. We review the incidence of thrombotic complications in glioma, the biology of the coagulome as related to glioma progression, prevention and treatment of thrombosis, the role of anticoagulants as anticancer therapy, and vascular complications such as ischemic stroke and intracranial bleeding. The coagulation cascade is intimately involved in cancer-related thrombosis, glioma progression, and vascular complications of glioma therapy. Tissue factor is the principal initiator of coagulation and is upregulated in a glioma subtype-specific fashion. Short-term (perioperative) antithrombotic prophylaxis is effective, but long-term anticoagulation, although attractive, is not routinely indicated. Most patients with symptomatic venous thromboembolism can be safely anticoagulated, including those on anti-vascular endothelial growth factor therapeutics such as bevacizumab. Initial therapy should include low-molecular-weight heparin, and protracted anticoagulant treatment, perhaps indefinitely, is indicated. Many complex interactions resulting in vessel wall injury can lead to ischemic stroke, intracranial and intratumoral hemorrhage, and long-term sequelae such as cognitive impairment.

Hypercoagulability and Mortality of Patients with Stroke and Active Cancer: The OASIS-CANCER Study

Background and Purpose

Patients with active cancer are at an increased risk for stroke. Hypercoagulability plays an important role in cancer-related stroke. We aimed to test whether 1) hypercoagulability is a predictor of survival, and 2) correction of the hypercoagulable state leads to better survival in patients with stroke and active cancer.

Methods

We recruited consecutive patients with acute ischemic stroke and active systemic cancer between January 2006 and July 2015. Hypercoagulability was assessed using plasma D-dimer levels before and after 7 days of anticoagulation treatment. The study outcomes included overall and 1-year survival. Plasma D-dimer levels before and after treatment were tested in univariate and multivariate Cox regression models. We controlled for systemic metastasis, stroke mechanism, age, stroke severity, primary cancer type, histology, and atrial fibrillation using the forward stepwise method.

Results

A total of 268 patients were included in the analysis. Patients with high (3rd–4th quartiles) pre-treatment plasma D-dimer levels showed decreased overall and 1-year survival (adjusted HR, 2.19 [95% CI, 1.46–3.31] and 2.70 [1.68–4.35], respectively). After anticoagulation treatment, post-treatment D-dimer level was significantly reduced and independently associated with poor 1-year survival (adjusted HR, 1.03 [95% CI, 1.01–1.05] per 1 μg/mL increase, P=0.015). The successful correction of hypercoagulability was a protective factor for 1-year survival (adjusted HR 0.26 [CI 0.10–0.68], P=0.006).

Conclusions

Hypercoagulability is associated with poor survival after stroke in patients with active cancer. Effective correction of hypercoagulability may play a protective role for survival in these patients.

Spectrum of Cerebrovascular Disease in Patients with Multiple Myeloma Undergoing Chemotherapy-Results of a Case Control Study

Objectives

Patients with multiple myeloma (MM) are at increased risk of arterial thrombosis. Our aim was to determine the risk factors, mechanisms and outcome of strokes in these patients.

Methods

We conducted a retrospective matched case–control study from our database of MM patients enrolled in Total Therapy (TT) 2, TT3a and TT3b protocols who developed a vascular event (transient ischemic attack, ischemic stroke, or intracerebral hemorrhage) from October 1998 to January 2014. Cases were matched for age-matched selected controls. Baseline demographics, risk factors, MM characteristics, laboratory values, and mortality of cases were compared to those of controls. Multivariate logistic regression analysis identified risk factors associated with stroke. Ischemic strokes (IS) were classified with modified Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria.

Results

Of 1,148 patients, 46 developed a vascular event (ischemic stroke, 33; transient ischemic attack, 11; hypertensive intracerebral hemorrhage, 2). Multivariate logistic regression analysis determined renal insufficiency (odds Ratio, 3.528; 95% CI, 1.36–9.14; P = 0.0094) and MM Stages I and II (odds Ratio, 2.770, 95% CI, 1.31–5.81; p = 0.0073) were independent predictors of stroke. In our study, strokes attributable to hypercoagulability, atrial fibrillation and small-vessel occlusion were common mechanisms. After a stroke, 78% of patients were discharged to home or a rehabilitation facility and 4% to a long-term nursing facility; in-hospital mortality was 15%. Despite suffering a stroke no significant differences in survival were observed.

Conclusion

In our cohort of multiple myeloma patients, renal failure and MM Stages I and II had increased risk of stroke.

Risk of stroke in patients with newly diagnosed multiple myeloma: a retrospective cohort study

Cerebrovascular events are a common complication among patients with cancer, increasing morbidity and mortality. However, the association between multiple myeloma and cerebrovascular events remains unclear. We therefore investigated multiple myeloma patients' risk factors for stroke to devise a better stroke-prevention strategy. This study includes consecutive patients 20 years and older who were newly diagnosed with symptomatic multiple myeloma at Taipei Veterans General Hospital, a tertiary medical center, between January 1, 2002 and December 31, 2014. The primary outcome was stroke development. Patients with head injuries, brain tumors, brain parenchymal invasions, or antecedent malignancies were excluded. Hazard ratios (HRs) of stroke risk factors for multiple myeloma patients were estimated by Cox proportional regression analysis. Overall, 395 patients with a median age of 70 years were investigated. In the median follow-up period of 18 months, cerebrovascular events occurred in 16 patients, including 10 ischemic strokes and 6 hemorrhagic strokes. The 5-year estimated cumulative incidence rate was 7.45%. In the multivariate analysis, the κ light chain isotype (adjusted HR, 8.37; 95% confidence interval [CI], 1.91-39.8), previous cerebrovascular accidents (adjusted HR, 5.16; 95% CI, 1.48-17.9), and serum creatinine > 2 mg/dL (adjusted HR, 4.21; 95% CI, 1.10-16.0) were identified as independent risk factors for stroke. Subgroup analysis showed that atrial fibrillation (adjusted HR, 8.07) and previous cerebrovascular accident (adjusted HR, 4.89) are significant risk factors for ischemic stroke. Serum creatinine > 2 mg/dL (adjusted HR, 30.6) and previous cerebrovascular accident (adjusted HR, 13.9) are significant for hemorrhagic stroke. Moreover, therapeutic strategies for multiple myeloma were not associated with stroke in our study. This study demonstrates that risk of stroke increases in myeloma patients with a κ light chain isotype, previous cerebrovascular events, and renal impairment. Further prospective clinical studies to clarify the relationship between multiple myeloma and stroke are warranted.

Cancer Cell-Derived Extracellular Vesicles Are Associated with Coagulopathy Causing Ischemic Stroke via Tissue Factor-Independent Way: The OASIS-CANCER Study

Background

Cancer and stroke, which are known to be associated with one another, are the most common causes of death in the elderly. However, the pathomechanisms that lead to stroke in cancer patients are not well known. Circulating extracellular vesicles (EVs) play a role in cancer-associated thrombosis and tumor progression. Therefore, we hypothesized that cancer cell-derived EVs cause cancer-related coagulopathy resulting in ischemic stroke.

Methods

Serum levels of D-dimer and EVs expressing markers for cancer cells (epithelial cell adhesion molecule [CD326]), tissue factor (TF [CD142]), endothelial cells (CD31+CD42b-), and platelets (CD62P) were measured using flow cytometry in (a) 155 patients with ischemic stroke and active cancer (116 − cancer-related, 39 − conventional stroke mechanisms), (b) 25 patients with ischemic stroke without cancer, (c) 32 cancer patients without stroke, and (d) 101 healthy subjects.

Results

The levels of cancer cell-derived EVs correlated with the levels of D-dimer and TF+ EVs. The levels of cancer cell-derived EVs (CD326+ and CD326+CD142+) were higher in cancer-related stroke than in other groups (P<0.05 in all the cases). Path analysis showed that cancer cell-derived EVs are related to stroke via coagulopathy as measured by D-dimer levels. Poor correlation was observed between TF+ EV and D-dimer, and path analysis demonstrated that cancer cell-derived EVs may cause cancer-related coagulopathy independent of the levels of TF+ EVs.

Conclusions

Our findings suggest that cancer cell-derived EVs mediate coagulopathy resulting in ischemic stroke via TF-independent mechanisms.

Cerebral ischemic events in patients with pancreatic cancer: A retrospective cohort study of 17 patients and a literature review

Stroke is a dramatic complication of pancreatic cancer with mechanisms related to oncological disease. A better description of the characteristics of cerebrovascular events would help better understand the pathogeny and protect vulnerable patients. We thus conducted a descriptive analysis of clinical, biological, and radiological features of patients from our centers and literature.We reviewed consecutive cases of patients who presented cerebrovascular events and pancreatic cancer in 4 stroke units in Lorrain (France) between January 1, 2009 and March 31, 2015, and all reported cases of literature. We identified 17 cases in our centers and 18 reported cases. Fifty-seven per cent of patients were male. Median age was 63 ± 14 years and ranged from 23 to 81 years. All cerebral events were ischemic. At the onset of stroke, pancreatic cancer had already been diagnosed in 59% of the patients in our centers for a mean time of 5.4 months. Five of them (29%) were being treated with gemcitabine and 2 (12%) with folfirinox. Adenocarcinoma at metastatic stage was reported in 82% of cases overall. Brain imaging revealed disseminated infarctions in 64%. High median levels of D-dimer (7600 ± 5 × 10 μg/L), C-reactive protein (63 ± 43 mg/L), and elevated prothrombin time (19 ± 6 seconds) were found. Thirty-six per cent of patients explored with echocardiography were diagnosed with nonbacterial thrombotic endocarditis. Ten of our patients received anticoagulant therapy as secondary stroke prevention without any documented recurrence. Nevertheless, outcome was poor with a median survival time of 28 ± 14 days after stroke onset. Cerebral ischemic events occur at advanced stages of pancreatic cancer, most likely by a thromboembolic mechanism. Disseminated infarctions and high D-dimer, C-reactive protein levels, and a high prothrombin time are the most constant characteristics found in this context. All patients should be screened for nonbacterial thrombotic endocarditis as this etiology supports the use of anticoagulant therapy.

Case series of cerebral infarction with Trousseau's syndrome associated with malignant gynecological tumors

The association between neoplastic disease and thromboembolic disorders was first recognized by Trousseau in 1865. Blood coagulation abnormalities have been reported in the majority of patients with cancer, including those with ovarian carcinoma. However, Trousseau's syndrome (TS) has rarely been reported in women with ovarian carcinoma. We herein report a case series of TS, notably in the brain, in association with gynecological malignant disease, and emphasize the difficulties associated with the management of these thromboembolic effects. The aim of this study was to present our experience with 5 TS patients whose condition was effectively controlled through treatment of the primary malignant disease. Therefore, we suggest that patients with TS may be cured by tumor resection, even if they have severe thromboembolic disease, such as cerebral or pulmonary infarction.

Characteristics of cryptogenic stroke in cancer patients

Objective

To clarify the characteristics of cryptogenic stroke in patients with active cancer.

Methods

Patients with or without cancer diagnosed with acute ischemic stroke between January 2006 and February 2015 were extracted from a prospectively collected stroke database of Osaka University Hospital. Patients were categorized according to the presence of active cancer and known stroke mechanisms.

Results

Among 1191 patients with acute ischemic stroke, 145 (12%) had active cancer. Patients with active cancer were diagnosed more often with cryptogenic stroke than were patients without cancer (47% vs. 12%, P < 0.001). Compared with cryptogenic stroke patients without cancer, cryptogenic stroke patients with active cancer had fewer atherosclerotic risk factors, lower nutrition status, higher plasma D‐dimer levels, and multiple vascular lesions. In a multivariate logistic analysis, plasma D‐dimer level (odds ratio [OR] per 1 standard deviation increase: 6.30; 95% confidence interval [CI]: 2.94–15.69; P < 0.001), and the presence of multiple vascular lesions (OR: 6.40; 95% CI: 2.35–18.35; P < 0.001) were independent predictors of active cancer. When comparing active cancer patients who had known stroke mechanisms with those who had cryptogenic stroke, high plasma D‐dimer levels, multiple vascular lesions, and receiving chemotherapy and/or radiation therapy were associated with cryptogenic stroke etiology.

Interpretation

In cryptogenic stroke, patients with active cancer has a unique pathology characterized by high plasma D‐dimer levels and multiple vascular lesions. The hypercoagulable state and malnutrition due to cancer and its treatments potentially influence the development of cryptogenic stroke in cancer patients.

Ischemic Stroke in Critically Ill Patients with Malignancy

Background

Cerebrovascular diseases are a frequent cause of neurological symptoms in patients with cancer. The clinical characteristics of ischemic stroke (IS) in patients with cancer have been reported in several studies; however, limited data are available regarding critically ill patients with cancer who develop IS during their stay in the intensive care unit (ICU).

Methods

All consecutive patients who underwent brain magnetic resonance imaging (MRI) for suspicion of IS with acute abnormal neurologic symptoms or who developed signs of IS while in the ICU were retrospectively evaluated. We compared the clinical characteristics and diffusion-weighted imaging (DWI) lesion patterns between patients finally diagnosed as having or not having IS.

Results

Over the study period, a total of 88 patients underwent brain MRI for suspicion of IS, with altered mental status in 55 (63%), hemiparesis in 28 (32%), and seizure in 20 (23%). A total of 43 (49%) patients were ultimately diagnosed with IS. Multiple DWI lesions (41%) were more common than single lesions (8%). The etiologies of IS were not determined in the majority of patients (n = 27, 63%). In the remaining 16 (37%) patients, the most common aetiology of IS was cardioembolism (n = 8), followed by large-vessel atherosclerosis (n = 3) and small-vessel occlusion (n = 2). However, brain metastases were newly diagnosed in only 7 (8%) patients. Univariate comparison of the baseline characteristics between patients with or without IS did not reveal any significant differences in sex, malignancy type, recent chemotherapy, vascular risk factors, or serum D-dimer levels at the time of suspicion of IS. Thrombotic events were more common in the IS group than in the non-IS group (P = 0.028). However, patients who were ultimately diagnosed with IS had more hemiparesis symptoms at the time of suspicion of IS (P = 0.001). This association was significant even after adjusting for potentially confounding factors (adjusted odds ratio 5.339; 95% confidence interval, 1.521–19.163).

Conclusions

IS developed during ICU stays in critically ill patients with cancer have particular features that may be associated with cancer-related mechanism.

Cancer-related Stroke due to Mural Thrombus in the Extracranial Carotid Artery

A 41-year-old man was admitted to our hospital because of a cancer-related stroke (CRS) caused by a thrombus of the extracranial carotid artery. He had undergone neoadjuvant radiochemotherapy for metastatic colorectal adenocarcinoma. The serum D-dimer values were within the normal range. We treated him with intravenous unfractionated heparin followed by warfarin. There were no recurrent stroke events over six months. The leading cause of a CRS is an embolism caused by hypercoagulopathy, mainly represented by non-bacterial thrombotic endocarditis. However, it was unusual that, in the current case, a thrombus of the extracranial carotid artery was formed with no significant residual stenosis, thus resulting in an artery-to-artery embolism.