Stroke in patients with cancer: Incidence and etiology

A review of hereditary and acquired coagulation disorders in the aetiology of ischaemic stroke

The diagnostic workup in patients with ischaemic stroke often includes testing for prothrombotic conditions. However, the clinical relevance of coagulation abnormalities in ischaemic stroke is uncertain. Therefore, we reviewed what is presently known about the association between inherited and acquired coagulation disorders and ischaemic stroke, with a special emphasis on the methodological aspects. Good-quality data in this field are scarce, and most studies fall short on epidemiological criteria for causal inference. While inherited coagulation disorders are recognised risk factors for venous thrombosis, there is no substantial evidence for an association with arterial ischaemic stroke. Possible exceptions are the prothrombin G20210A mutation in adults and protein C deficiency in children. There is proof of an association between the antiphospholipid syndrome and ischaemic stroke, but the clinical significance of isolated mildly elevated antiphospholipid antibody titres is unclear. Evidence also suggests significant associations of increased homocysteine and fibrinogen concentrations with ischaemic stroke, but whether these associations are causal is still debated. Data on other acquired coagulation abnormalities are insufficient to allow conclusions regarding causality. For most coagulation disorders, a causal relation with ischaemic stroke has not been definitely established. Hence, at present, there is no valid indication for testing all patients with ischaemic stroke for these conditions. Large prospective population-based studies allowing the evaluation of interactive and subgroup effects are required to appreciate the role of coagulation disorders in the pathophysiology of arterial ischaemic stroke and to guide the management of individual patients.

[Clinical characteristics of ischemic stroke in elderly patients with cancer]

AIM

We classified acute ischemic stroke patients with cancer according to their causal relations, and attempted to evaluate the clinical characteristics of ischemic stroke associated with cancer.

METHODS

This is a retrospective study of all acute ischemic stroke patients admitted to our hospital between January 2006 and March 2009. Among acute ischemic stroke patients, we identified 30 patients with a history of cancer, or who developed cancer within 1 year from their ischemic stroke onset. There were 2 patients excluded from our evaluation because they had undergone extirpation of their cancer more than 5 years before stroke onset, and no recurrence of cancer within 5 years of stroke onset was noted. Finally, 28 patients were enrolled and evaluated in this study. Ischemic stroke was classified based on the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. In addition, we classified the patients according to their causal relations of ischemic stroke with cancer.

RESULTS

The median patient age was 74 years (range, 56 to 91 years); 68% of patients were men. Of these, 8 (29%) were classified into an ischemic stroke related to cancer group. There was a higher prevalence of ischemic stroke related to cancer in patients under 75 years old with clinical stage IV cancer (p=0.02). D-dimer tended to be higher in those patients with ischemic stroke related to cancer in this study (p=0.13).

CONCLUSION

Ischemic stroke related to cancer was found more frequently in patients under 75 years old with advanced cancer. Additionally, D-dimer tended to be higher in those patients with ischemic stroke related to cancer.

Neurological complications of systemic cancer

Neurological complications of systemic cancer-those arising outside the nervous system-can be distressing, disabling, and sometimes fatal. Diagnosis is often difficult because different neurological disorders may present with similar signs and symptoms. Furthermore, comorbid neurological illnesses, common in elderly patients with cancer, can complicate diagnosis. Early diagnosis and aggressive treatment can improve neurological symptoms and can substantially enhance a patient's quality of life. We approach the problem of neurological complications of systemic cancer as would a neurologist: first by identifying the anatomical area or areas that are affected (ie, brain, spinal cord, peripheral nerve), then by evaluating the diagnostic approach, considering the symptoms and signs and including appropriate laboratory tests, and finally, by recommending treatment. We focus on disorders that are difficult to diagnose, need neurological consultation, and for which effective treatments exist.

Cerebral edema, altered mental status, seizures, acute stroke, leptomeningeal metastases, and paraneoplastic syndrome

Neurologic symptoms commonly occur in oncology patients, and in some cases they may be the presenting symptom of malignancy. Cancer-related neurologic syndromes are rarely pathognomonic and must be differentiated from other benign or serious conditions. This article reviews common neuro-oncologic syndromes that may lead to urgent evaluation in the emergency department, including cerebral edema, altered mental status, seizures, acute stroke, leptomeningeal metastases, and paraneoplastic neurologic syndromes.

[Ischemic strokes as a presenting feature of marantic endocarditis despite heparin treatment]

We report on two patients hospitalized in intensive care unit for ischemic strokes presenting the feature of marantic endocarditis complicating lung's adenocarcinoma. These two cases turned out to be very interesting because of the occurrence of ischemic strokes even though the patients were receiving the recommended treatment, namely anticoagulation with heparin, in well-adjusted doses. The management of nonbacterial thrombotic endocarditis remains a challenge and its mortality is still high.

Hyperperfusion on magnetic resonance imaging in acute chemotherapy-related leukoencephalopathy

Acute chemotherapy-related leukoencephalopathy can present similar to acute stroke with symptoms including aphasia, dysarthria, and hemiplegia. Differentiation based on clinical appearance is challenging, and physicians must distinguish between the 2 conditions rapidly to institute appropriate therapies. An 8-year-old male with acute lymphoblastic leukemia receiving chemotherapy, including intrathecal methotrexate, presented to our emergency center with 2 hours of expressive aphasia and flaccid right hemiplegia. Emergent magnetic resonance imaging (MRI) was obtained, demonstrating diffusion restriction within bilateral corona radiata and centrum semiovale. Magnetic resonance perfusion revealed mildly increased perfusion, a finding inconsistent with ischemic stroke and previously unreported in acute chemotherapy-related leukoencephalopathy without necrosis. This increased perfusion conclusively eliminated stroke from the clinical differential. Magnetic resonance perfusion imaging proved valuable to rapidly distinguish acute chemotherapy-related leukoencephalopathy from ischemia, and the evaluation of perfusion alterations in this disorder may provide further insight into the pathophysiology of this entity.

Ischemic stroke in cancer patients with and without conventional mechanisms: a multicenter study in Korea

BACKGROUND AND METHODS

To assess the precise mechanisms of stroke in cancer patients, we analyzed the data for cancer patients with acute ischemic stroke registered from 6 centers in South Korea. Clinical features, risk factors, diffusion-weighted imaging lesion patterns, and laboratory findings including D-dimer levels were compared between patients with conventional stroke mechanisms (CSMs) and cryptogenic group.

RESULTS

A total of 161 patients were included in this study: 97 (60.2%) patients in the CSM group and 64 (39.8%) in the cryptogenic group. Patients in the CSM group were older and vascular risk factors were more prevalent than in the cryptogenic group. Diffusion-weighted imaging patterns of multiple lesions involving multiple arterial territories were observed more frequently in the cryptogenic group than in the CSM group. In addition, levels of the D-dimer were higher in the cryptogenic group than in the CSM group (11.5+/-14.6 versus 3.6+/-10.3 microg/dL). In multivariate analysis, the diffusion-weighted imaging lesion pattern of multiple vascular territories (odds ratio, 11.2; 95% CI, 3.74 to 33.3), and D-dimer levels of >1.11 microg/dL (odds ratio, 10.6; 95% CI, 3.29 to 33.8) were associated independently with the cryptogenic group.

CONCLUSIONS

Stroke outside of CSM occurred in a large number in cancer patients. In stroke patients with cancer, d-dimer levels and diffusion-weighted imaging lesion patterns may be helpful in early identification of non-CSMs (especially coagulopathy associated with cancer) and possibly in guiding preventive strategies for stroke.

Vorinostat (NSC# 701852) in patients with relapsed non-small cell lung cancer: a Wisconsin Oncology Network phase II study

INTRODUCTION

Vorinostat is a small molecule inhibitor of histone deacetylase, and has shown preclinical activity in non-small cell lung cancer (NSCLC).

METHODS

Patients with relapsed NSCLC were eligible. Patients received oral vorinostat, 400 mg daily. The primary objective was response rate, with the goal of at least one responder in the first 14 evaluable patients, according to the two-stage minimax design. Secondary objectives included time to progression (TTP), overall survival (OS), and safety.

RESULTS

Sixteen patients enrolled from January 2006 to April 2007. The median age was 59.5 years. Thirteen patients were female. Two patients were not evaluable for response due to progressive disease within Cycle 1. No objective antitumor responses were seen in the 14 evaluable patients. Eight patients experienced stable disease (median 3.7 months, range 1.4-19.4). Median TTP was 2.3 months (range 0.9-19.4 months), median OS was 7.1 months (range 1.4-30.0+ months), and estimated 1 year OS rate was 19% (SE 10%). One patient died on study from an acute ischemic stroke; this event was deemed possibly related to treatment. Grade 3/4 adverse events possibly related to vorinostat included neutropenia, lymphopenia, fatigue, pulmonary embolus/deep vein thrombosis, dehydration, elevated alkaline phosphatase, and hypokalemia.

CONCLUSIONS

No objective antitumor activity was detected with single agent vorinostat in this setting; however, it yields TTP in relapsed NSCLC similar to that of other targeted agents. Further studies in NSCLC should focus on combining vorinostat with other antitumor agents.

Management of epilepsy in oncological patients

INTRODUCTION

Comorbidity between epilepsy and cancer is elevated. As a life-time condition, it is not impossible for a patient with epilepsy to have a cancer at some point. Besides, at least 30% of patients with primary brain tumors have epileptic seizures, but also in patients with metastatic infiltrating lesions of the central nervous system and with extracerebral tumors, epilepsy can be related. Seizures may also appear associated with paraneoplastic syndromes, such as limbic encephalitis and metabolic and infectious complications of chemotherapy and radiotherapy.

RESULTS

The precise mechanisms by which brain tumors and the other conditions mentioned above produce seizures are not fully understood, but are reviewed in this article, as well as the many different therapeutic options that may be used in the treatment of epileptic seizures. Pharmacological treatment poses various controversies, such as the utility of prophylactic treatment, interactions between antiepileptic drugs (AEDs) and chemotherapeutic drugs and the complications derived from the adverse effects of AEDs in this population. Finally, other treatments are proposed such as chemotherapy, radiotherapy and surgery, the rational application of which allows for an improvement in the patients' quality of life.

CONCLUSION

In order to arrive at a diagnosis, the different causes that could condition the appearance of epileptic seizures in cancer patients must be known. After this, the most adequate treatment should be chosen, thus ensuring the comprehensive treatment of cancer and epilepsy.

Stroke in cancer patients: a risk factor analysis

BACKGROUND AND PURPOSE

In patients already suffering from cancer, the additional occurrence of stroke can aggravate the burden of the disease. The purpose of this study was to compare risk factors for haemorrhagic and ischemic strokes in cancer and non-cancer patients.

METHODS

A retrospective analysis, including 1,274 stroke patients admitted to a stroke unit, was conducted from 2004 to 2007. Classical risk factors for stroke and clinical outcome measures were compared between cancer and non-cancer patients.

RESULTS

Twelve percent of stroke patients had an additional diagnosis of cancer. In the non-cancer population, 84% had ischemic and 16% had haemorrhagic strokes. In cancer patients, 86% had ischemic and 14% had haemorrhagic strokes. Vascular risk factors in cancer patients, including hypertension, atrial fibrillation, coronary vessel disease, smoking, hypercholesterolemia and diabetes mellitus, showed no difference compared to the non-cancer population. Only thrombotic events occurred more often in the cancer cohort. The most frequent cancer types were urogenital, breast and gastrointestinal. Regarding clinical outcome, cancer patients had an inferior neurological condition at discharge and a trend towards a longer stay in the stroke unit.

CONCLUSIONS

The frequency of ischemic and haemorrhagic stroke in tumour patients is similar to that in the non-cancer population. Cerebrovascular risk factors do not significantly vary between cancer and non-cancer patients. The higher frequency of thrombotic events in cancer patients may reflect a coagulation disorder, commonly found in patients with malignancy. Clinical outcome in cancer patients may be worsened by the pre-existent co-morbidity.

Stroke and cancer: a review

Stroke is a disabling disease and can add to the burden of patients already suffering from cancer. Several major mechanisms of stroke exist in cancer patients, which can be directly tumour related, because of coagulation disorders, infections, and therapy related. Stroke can also occur as the first sign of cancer, or lead to its detection. The classical literature suggests that stroke occurs more frequently in cancer patients than in the average population. More recent studies report a very similar incidence between cancer and non-cancer patients. However, there are several cancer-specific types and causes of stroke in cancer patients, which need to be considered in each patient. This review classifies stroke into ischaemic, haemorrhagic, cerebral venous thrombosis and other rarer types of cerebrovascular disease. Its aim is to identify the types of stroke most frequently associated with cancer, and give a practical view on the most common and most specific types of stroke. The diagnosis of the cause of stroke in cancer patients is crucial for treatment and prevention. Management of different stroke types will be briefly discussed.

First-ever stroke as initial presentation of systemic cancer

BACKGROUND

Stroke is a frequent complication in patients with cancer, occurring in nearly 15% of patients with cancer. However, cerebrovascular disease as the first manifestation of cancer has rarely been reported.

METHODS

We retrospectively reviewed all 5106 patients admitted for ischemic stroke to our stroke department between 1991 to 2004, and identified a group of 24 patients (0.4%) who had an underlying malignancy.

RESULTS

The mean age of the 24 patients was 52 +/- 4.1 years and 62.5% were women. Vascular risk factors were found in only 41% of patients. The principal mechanisms of stroke pathogenesis were nonbacterial thrombotic endocarditis (8/24), diffuse intravascular coagulation (6/24), and atherosclerosis (5/24). The most frequent neoplasms were lung and breast cancer. All patients but 4 were diagnosed with an underlying malignancy at the second ischemic event. Mean follow-up of surviving patients was 29 months (3-60). Nineteen patients died (79%), with a median survival of 58 days after cerebral infarction.

CONCLUSIONS

A systemic cancer workup should be considered in patients in whom stroke origin is unclear or who have an early vascular recurrence. Stroke as the first manifestation of an underlying malignancy is mostly secondary to specific cancer-related causes. Outcome is poor and correlates with both severity of neurologic disability and the stage of tumor.

Interobserver agreement in the trial of org 10172 in acute stroke treatment classification of stroke based on retrospective medical record review

BACKGROUND

The reliability of the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification system of stroke in siblings of stroke-affected probands has not been tested. Similarly, the reliability of using clinical medical records to classify ischemic stroke has not been assessed. The purpose of this study was to establish the interrater reliability of sibling stroke subtyping by applying the TOAST criteria to retrospectively obtained medical records.

METHODS

Thirty medical records were randomly sampled from among the records of all siblings previously classified as stroke affected by the Siblings with Ischemic Stroke Study (SWISS) Stroke Verification Committee. Blinded medical records for these individuals were sent to 6 physician reviewers who independently classified TOAST stroke subtype on the basis of record review.

RESULTS

Using the kappa statistic to assess interrater reliability, the overall reliability (SE) for assigning a TOAST subtype of stroke was 0.54 (0.03). Pair-wise comparisons between the original SWISS Stroke Verification Committee diagnoses and the diagnoses made by other reviewers exhibited moderate reliability (kappa range 0.41-0.56). The kappa statistics for common stroke subtypes were large vessel, 0.80 (0.06); cardioembolic, 0.80 (0.06); small vessel, 0.53 (0.06); and unknown cause, 0.40 (0.06).

CONCLUSION

We conclude that TOAST subtyping had moderate interrater reliability. Large-artery and cardioembolic subtype diagnoses seemed most reliable.

Management of stroke in cancer

Cerebrovascular disorders, including brain infarction, brain hemorrhage, and cerebral venous thrombosis, can occur as an early sign of cancer, but typically occur late in the clinical course. These disorders are due to a variety of pathogenic mechanisms, including coagulation disorders associated with the cancer, invasion or compression of vessels from tumor in or adjacent to the brain, and the adverse effects of cancer therapy. The appropriate therapy for these cerebrovascular disorders is empiric in most instances, because as yet there are no prospective treatment trials for them. A review of the existing literature reveals that improvement in patient quality of life and prevention of further cerebrovascular events can be obtained in some clinical situations.

[Nonbacterial thrombotic endocarditis and gastric carcinoma]

We report a 74-year-old woman with acute heart failure and recurrent ischemic strokes as the presenting features of a nonbacterial thrombotic endocarditis complicating a gastric adenocarcinoma. The treatment only allowed a few months remission. Diagnosis of nonbacterial thrombotic endocarditis is rarely obtained while the patient is alive. Coagulation abnormalities due to the tumoral process are responsible of the valvular thrombotic process. Anticoagulation with heparin is recommended. Valvular surgery remains controversial.

Primitive neuroectodermal tumor of the myometrium with cardio-vascular symptoms

BACKGROUND

Non-bacterial thrombotic endocarditis is a severe complication of cancer, rarely reported in gynecologic tumors. However, it can be inaugural and lead to complex diagnostic pathways.

CASE

A 40-year-old woman presented with a stroke, related to an endocarditis. The valvular vegetation was surgically removed, and a malignant node was resected. A PET-scan led to the diagnosis of a myometrial tumor, which was found to be a primitive neuroectodermal tumor (PNET). The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, and systemic chemotherapy which allowed a complete remission of tumoral and cardio-vascular symptoms.

CONCLUSION

To our knowledge, this is the first case report of a PNET of the myometrium revealed by cardio-vascular symptoms.

Multifocal strokes as the presentation of occult lung cancer

Cancer patients are hypercoagulable through a variety of mechanisms and are at significant risk for ischemic stroke. Though usually occurring in the later stages of neoplastic disease, stroke can rarely be the first manifestation of an occult malignancy. We report a 46-year-old woman who presented with multiple cerebral infarctions in numerous vascular distributions, refractory to anticoagulation, and associated with systemic thromboses. These atypical features prompted a malignancy evaluation which revealed an occult lung adenocarcinoma. Our patient had a rapidly deteriorating course with recurrent strokes despite numerous anti-platelet and anti-coagulant agents, and was only responsive to chemotherapy aimed at the underlying cancer.

Stroke as the first manifestation of concealed cancer

BACKGROUND AND PURPOSE

Trousseau's syndrome (TS) is defined as a malignancy-related thromboembolism occurring in patients with an underlying or undiagnosed malignancy. Stroke seldom occurs as the first manifestation of a cancer. We investigated the clinical and radiological features of patients with TS.

METHODS

We reviewed the clinical, pathologic, and radiological records of consecutive stroke patients, whose cancers were diagnosed at stroke presentation. Cancer-related stroke was defined if no definite cause was confirmed and malignancy was detected within 6 months of first stroke onset without cancer-related treatment. All patients underwent brain diffusion-weighted MRI (DWI), MR angiography, and echocardiography. The sizes, numbers, and locations of all hyperintense lesions in the DWI were noted.

RESULTS

Ten patients were finally analyzed. Histologically, cancers were often proven to adenocarcinomas (50%, 5/10) of advanced stage. Six of 10 patients tested (60%) had elevated D-dimer. Seven of the 10 patients (70%) showed bihemispheric anterior and posterior involvement. DWI features showed numerous small and medium or large lesions in multiple territories in 9 patients (90%).

CONCLUSIONS

The authors emphasize that when presented with multiple bihemispheric infarctions on DWI and an unknown etiology, the neurologist must consider the existence of a concealed cancer.

Seizures and epilepsy in oncological practice: causes, course, mechanisms and treatment

There are few data available on the causes and mechanistic basis, outcome and treatment of seizures and epilepsy in people with systemic cancer. Seizures and epilepsy in people with cancers other than primary brain tumours are reviewed here. Articles published in English, which discussed the neurological manifestations and complications of cancer and its treatment, were searched and information on the frequency, aetiology, and course of seizures and epilepsy was extracted. The frequency, aetiology and outcome of seizure disorders in patients with cancer differ from those in the general population. Intracranial metastasis, cancer drugs and metabolic disturbances are the most common causes. Infections, cerebrovascular complications of systemic cancer and paraneoplastic disorders are among the rarer causes of seizures in patients with neoplasms. Several drugs used in the treatment of cancer, or complications arising from their use, can trigger seizures through varied mechanisms. Most drug-induced seizures are provoked and do not require long-term treatment with antiepileptic drugs.

Stroke risk factor, pattern and outcome in patients with cancer

OBJECTIVE

To investigate risk factors, stroke pattern and outcome in stroke patients with cancer.

METHODS

A retrospective review of all stroke patients with cancer (n = 69) admitted to Bankstown-Lidcombe Hospital, Sydney, Australia, between January 1999 and December 2004 was conducted, and comparison made to age- and gender-matched non-cancer stroke patients admitted to the same hospital during the same period.

RESULTS

Vascular risk factors did not significantly differ between cancer and non-cancer groups. There was a trend towards greater risk of intracerebral haemorrhage in the cancer group vs the non-cancer group. Previous deep vein thrombosis was more common, and prothrombin time and activated partial thromboplastin time were prolonged in the cancer group vs the non-cancer group. More patients died in hospital in the cancer group vs the non-cancer group.

CONCLUSIONS

Coagulation disorders are more likely to be seen in stroke patients with cancer, and patients with cancer have a higher in-hospital post-stroke mortality.

Risk Factor, Pattern, Etiology and Outcome in Ischemic Stroke Patients with Cancer: A Nested Case-Control Study

BACKGROUND

Coagulation disorders are seen in cancer patients, but it is not clear whether cancer predisposes stroke patients to unique characteristics. The aim of the study was to investigate risk factors, pattern,etiology and outcome in stroke patients with cancer.

METHODS

A retrospective review of all ischemic stroke (IS) patients with cancer (n = 56) admitted to Bankstown-Lidcombe Hospital, Sydney, Australia, between January 1999 and December 2004 was conducted and comparison made to age- and gender-matched noncancer IS patients admitted to the same hospital during the same period.

RESULTS

Vascular risk factors and stroke pattern were comparable in cancer and noncancer groups. Post-stroke thrombotic episodes (myocardial infarction, deep vein thrombosis or pulmonary emboli) were more common in the cancer group than in the noncancer group (11 vs. 0%, p = 0.031). Depression was also more common in the cancer group than in the noncancer group (14 vs. 2%, p = 0.039). There was a tendency for more patients in the cancer group to die in hospital (30 vs. 14%, p = 0.078).

CONCLUSIONS

Coagulation disorders were more likely to be seen in stroke cancer patients, and patients with cancer tended to have a higher in-hospital post-stroke mortality. Larger sample size studies may identify further differences in the characteristics of stroke patients with cancer.

Ischaemic stroke with malignancy may often be caused by paradoxical embolism

BACKGROUND

Although ischaemic stroke with malignancy occasionally occurs, the mechanisms of stroke in such cases have not been investigated in detail.

OBJECTIVE

To examine the mechanisms of ischaemic stroke with malignancy, particularly in relation to right-to-left shunt (RLS).

METHODS

Consecutive patients with ischaemic stroke within 24 h of stroke onset were prospectively studied. Contrast saline transcranial Doppler examination was carried out for all patients, to investigate the presence of RLS. When patients with stroke had RLS, deep venous thrombosis (DVT) or pulmonary embolism was assessed to diagnose paradoxical brain embolism.

RESULTS

Participants comprised 184 consecutive patients (115 men and 69 women) with a mean (standard deviation (SD)) age of 73 (11.8) years and mean (SD) National Institutes of Health Stroke Scale (NIHSS) score of 8 (7.4). RLS was detected in 32 of 184 (18%) patients. Malignancy was present in 11 (5%) patients. RLS was more frequent in patients with malignancy than in patients without malignancy (55% v 15%, respectively; p = 0.001). All six patients with RLS and malignancy displayed DVT or pulmonary embolism with severe disability (modified Rankin Scale 4-5) before stroke onset.

CONCLUSION

Paradoxical brain embolism should be considered to be an important mechanism in patients with stroke and malignancy.

Paraneoplastic syndromes affecting the nervous system

The paraneoplastic neurologic disorders (PND) are a diverse group of diseases characterized by the presence of neurologic dysfunction in the setting of a remote cancer. PND can affect almost any part of the nervous system, and are most commonly associated with lung cancer (small cell) and gynecologic tumors. Laboratory studies have demonstrated that an autoimmune response links the neurologic disorder and the cancer, and established a model whereby the cancer is believed to initiate the syndrome by expressing a protein antigen normally expressed in the nervous system, leading to anti-tumor immune response followed by autoimmune neurologic symptoms. We review the currently known PND and their pathogenesis.

Stroke in cancer patients

Cancer patients are at increased risk for stroke from direct and indirect effects of their malignancy. Some tumors are at high risk for cerebrovascular complications. Certain stroke mechanisms are specific to cancer, such as compression and occlusion of cerebral vessels by tumor, coagulopathy predisposing to hemorrhage and thrombosis, and treatment-related atherosclerosis. Special consideration for these mechanisms needs to be made when evaluating cancer patients, and treatment aimed at secondary prevention needs to incorporate overall prognosis and goals of care.

Yield of transesophageal echocardiography for nonbacterial thrombotic endocarditis and other cardiac sources of embolism in cancer patients with cerebral ischemia

Cerebrovascular events occur frequently in patients who succumb to cancer, and nonbacterial thrombotic endocarditis (NBTE) is a frequent postmortem finding in these patients. Despite the excellent diagnostic accuracy of transesophageal echocardiography (TEE) for cardiac sources of cerebral embolism, however, the prevalence of NBTE and other cardioembolic sources in patients with cancer and cerebral ischemia has not been investigated using this modality. This study examined the frequency of cardioembolic findings in consecutive patients with cancer referred to our institution for TEE evaluation of cerebrovascular events. The study cohort comprised 51 patients, of whom 18% had marantic vegetations, and 47% and 55% of whom had definite and definite or probable cardiac sources of embolism, respectively. The present study documents, for the first time, a high frequency of marantic endocarditis and other cardioembolic sources in patients with cancer and cerebrovascular events selected for TEE. This finding has important implications for evaluation and management in this patient population.

Treatment of medical complications in patients with brain tumors

Patients with primary brain tumors and those with cerebral metastases are at risk throughout their illness for several major medical problems, including vasogenic edema, seizures, and symptomatic venous thrombosis. In turn, the corticosteroids, anti-epileptic drugs, and anticoagulants used to treat these problems may produce significant adverse effects and result in important drug-drug interactions that may complicate chemotherapy. Although few Class I studies address any of these issues, guidelines can be offered to maximize quality of life and minimize hospital readmissions. Optimal management of brain edema involves minimizing corticosteroid use and tapering the steroid dose slowly to avoid steroid withdrawal symptoms. Prophylaxis of Pneumocystis pneumonia is necessary for patients requiring corticosteroids for more than 1 month. Anti-epileptic drugs (AEDs) should be avoided unless patients experience seizures. If possible, non-CTY (P450) enzyme-inducing drugs should be chosen. AED levels should be obtained frequently during corticosteroid taper. Multimodality venous thrombosis prophylaxis should begin at the time of the original surgery with external leg compression and unfractionated subcutaneous heparin or a low molecular weight heparin (LMWH). Brain tumor patients with symptomatic venous thrombosis or pulmonary embolism can be anticoagulated safely with warfarin or with LMWH, and LMWHs are preferable from the standpoints of efficacy, safety, and convenience for long-term outpatient treatment of venous thrombosis. Clinicians should be aware of potential drug-drug interactions between prescribed AEDs and chemotherapy and possible interactions with complementary and alternative therapies chosen by their patients. They also should be aware of interventions to minimize late sequelae of brain tumors and their treatment, including cognitive decline, depression, and increased stroke risk.

Incidence and etiology of cerebrovascular disease in patients with malignancy

Cerebrovascular disease is common in cancer patients and often arises from mechanisms unique to malignancy. Direct tumor effects include intratumoral hemorrhage, arterial and venous sinus invasion by tumor mass or leptomeningeal infiltrates, and tumor emboli. Complications of chemotherapy, radiation therapy, and hematopoietic stem-cell transplantion for cancer can occur before, during, or years after treatment. Coagulopathic conditions involve disseminated intravascular coagulation, thrombocytopenia, nonbacterial thrombotic endocarditis, and cerebral intravascular coagulation. Finally, septic infarction from fungal or bacterial sepsis and infectious vasculitis manifest in cancer patients immunocompromised by malignancy or cancer therapy. In many cases a combination of mechanisms is causative, and both hemorrhagic and ischemic stroke can occur simultaneously. Stroke type and mechanism, as well as the stage and pathology of the neoplasm, dictate proper management and help delineate prognosis.

Incidence of ischemic stroke post-chemotherapy: a retrospective review of 10,963 patients

OBJECTIVE

Vascular occlusion is not an uncommon event in malignancy. However, the frequency of ischemic stroke after chemotherapy has been mentioned only occasionally in clinical studies. A large-scale study is lacking.

METHODS

A retrospective study was conducted at Chang Gung Memorial Hospital, Kaohsiung, Taiwan, to analyze the incidence of ischemic stroke post-chemotherapy, further, to evaluate a possible causative relationship between the ischemic stroke and the chemotherapy regimen, the interval between the latest chemotherapy session and onset of ischemic stroke and the survival of patients with ischemic stroke post-chemotherapy. The data were retrieved from the Cancer Database from 1993 to 2004.

RESULTS

During this period, a total of 10,963 patients, with malignancies were followed-up for 1 month after chemotherapy, underwent 45,294 chemotherapy sessions. Among this group, there were 15 patients experiencing 16 ischemic strokes within the first month after the latest chemotherapy. Among them, 14 patients were followed-up until death and one patient was lost in follow-up after discharge against medical advice. The incidence of post-chemotherapy ischemic stroke was 0.137% and the frequency of chemotherapy cycles complicated by ischemic stroke was 0.035%. Adenocarcinoma was the most common histological type not only in ischemic stroke (40%) but also in overall patients (36.7%). The hemispheric stroke with middle cerebral artery territory involvement was the most common image finding. Platinum compounds, especially cisplatin, were the most commonly used chemotherapeutic agents for ischemic stroke patients. Twelve (75%) of these 16 ischemic strokes occurred within 10 days of the latest chemotherapy session and 10 (62.5%) occurred after the first cycle of chemotherapy. The median survival after ischemic stroke was 4 weeks.

CONCLUSION

Our results provide valuable data on the relationship between malignancy, treated with chemotherapy, and ischemic stroke. The risk of ischemic stroke after chemotherapy is predicted by the use of cisplatin-based chemotherapy not cancer histologic type. Infarction usually involves the territorial subtype, causes obvious neurological disabilities and carries a grave prognosis.