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Costamagna G, Navi BB, Beyeler M, Hottinger AF, Alberio L, Michel P. Ischemic Stroke in Cancer: Mechanisms, Biomarkers, and Implications for Treatment. Semin Thromb Hemost 2024; 50:342-359. [PMID: 37506734 DOI: 10.1055/s-0043-1771270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Ischemic stroke is an important cause of morbidity and mortality in cancer patients. The underlying mechanisms linking cancer and stroke are not completely understood. Long-standing and more recent evidence suggests that cancer-associated prothrombotic states, along with treatment-related vascular toxicity, such as with chemotherapy and immunotherapy, contribute to an increased risk of ischemic stroke in cancer patients. Novel biomarkers, including coagulation, platelet and endothelial markers, cell-free DNA, and extracellular vesicles are being investigated for their potential to improve risk stratification and patient selection for clinical trials and to help guide personalized antithrombotic strategies. Treatment of cancer-related stroke poses unique challenges, including the need to balance the risk of recurrent stroke and other thromboembolic events with that of bleeding associated with antithrombotic therapy. In addition, how and when to restart cancer treatment after stroke remains unclear. In this review, we summarize current knowledge on the mechanisms underlying ischemic stroke in cancer, propose an etiological classification system unique to cancer-related stroke to help guide patient characterization, provide an overview of promising biomarkers and their clinical utility, and discuss the current state of evidence-based management strategies for cancer-related stroke. Ultimately, a personalized approach to stroke prevention and treatment is required in cancer patients, considering both the underlying cancer biology and the individual patient's risk profile.
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Affiliation(s)
- Gianluca Costamagna
- Stroke Unit, Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas F Hottinger
- Services of Neurology and Oncology, Lundin Family Brain Tumor Research Center, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Hematology Central Laboratory, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Stroke Center, Neurology Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Xie W, Hsu S, Lin Y, Xie L, Jin X, Zhu Z, Guo Y, Chen C, Huang D, Boltze J, Li P. Malignancy-associated ischemic stroke: Implications for diagnostic and therapeutic workup. CNS Neurosci Ther 2024; 30:e14619. [PMID: 38532275 PMCID: PMC10965754 DOI: 10.1111/cns.14619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Patients with malignancies have an increased risk of suffering ischemic stroke via several mechanisms such as coagulation dysfunction and other malignancy-related effects as well as iatrogenic causes. Moreover, stroke can be the first sign of an occult malignancy, termed as malignancy-associated ischemic stroke (MAS). Therefore, timely diagnostic assessment and targeted management of this complex clinical situation are critical. FINDINGS Patients with both stroke and malignancy have atypical ages, risk factors, and often exhibit malignancy-related symptoms and multiple lesions on neuroimaging. New biomarkers such as eicosapentaenoic acid and blood mRNA profiles may help in distinguishing MAS from other strokes. In terms of treatment, malignancy should not be considered a contraindication, given comparable rates of recanalization and complications between stroke patients with or without malignancies. CONCLUSION In this review, we summarize the latest developments in diagnosing and managing MAS, especially stroke with occult malignancies, and provide new recommendations from recently emerged clinical evidence for diagnostic and therapeutic workup strategies.
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Affiliation(s)
- Wanqing Xie
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Szuyao Hsu
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yuxuan Lin
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Lv Xie
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Xia Jin
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Ziyu Zhu
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yunlu Guo
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Caiyang Chen
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Dan Huang
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | | | - Peiying Li
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Clinical Research Center, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Outcomes Research ConsortiumClevelandOhioUSA
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Hayakawa M. Cancer-Associated Stroke and Acute Endovascular Reperfusion Therapy. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:272-280. [PMID: 38025257 PMCID: PMC10657734 DOI: 10.5797/jnet.ra.2023-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/19/2023] [Indexed: 12/01/2023]
Abstract
Since stroke is often associated with cancer, acute stroke patients with cancer undergoing endovascular therapy (EVT) are not uncommon. Reportedly, the proportion of such cases is approximately 6%-7% of all stroke EVT cases. Ischemic stroke in patients with active cancer (cancer-associated stroke) includes not only strokes caused by cancer-related hypercoagulability but also coincident strokes due to common etiologies, strokes associated with tumor emboli, direct tumor invasion of blood vessels, and strokes associated with cancer therapy. Stroke caused by cancer-related hypercoagulability itself encompasses various entities, including paradoxical embolism, stroke due to nonbacterial thrombotic endocarditis, and in situ arterial occlusion due to disseminated intravascular coagulation or thrombotic microangiopathy. Thus, diverse mechanisms contribute to cancer-associated stroke, emphasizing the need to consider individualized treatment strategies for acute cases involving large vessel occlusion. Observational studies have shown that EVT for cancer-associated stroke results in poorer clinical outcomes, but with comparable rates of successful reperfusion and symptomatic intracranial hemorrhage when compared with stroke patients without cancer. This suggests that denying patients EVT solely on the basis of comorbid active cancer is inappropriate, and decision-making should be shared with the patients and their families, preferably through a multidisciplinary team approach. Thrombi retrieved from patients with stroke caused by cancer-related hypercoagulability have unique characteristics, being predominantly platelet rich and difficult to retrieve. Preprocedural imaging and serum biomarkers, including the hyperdense vessel sign on non-contrast CT, susceptibility vessel sign on T2* or susceptibility-weighted MRI, three-territory sign on MRI, and D-dimer levels, are valuable in evaluating the stroke subtype and thrombus features. Thrombectomy techniques, such as contact aspiration and stent retriever monotherapy, have shown varying degrees of effectiveness for stroke caused by cancer-related hypercoagulability, warranting further study. After reperfusion therapy, appropriate treatment for the prevention of stroke recurrence should be initiated, considering the specific stroke subtypes. In conclusion, cancer-associated stroke encompasses diverse subtypes, and thrombi associated with stroke caused by cancer-related hypercoagulability present various challenges for thrombectomy. Individualized treatment approaches based on underlying mechanisms are essential for improving outcomes in acute stroke patients with active cancer. Optimization of preprocedural diagnosis, EVT techniques, and secondary prevention of stroke caused by cancer-related hypercoagulability will lead to better management of these patients and enhance their quality of life.
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Affiliation(s)
- Mikito Hayakawa
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
- Department of Neurology, Institute of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Jhou HJ, Yang LY, Chen PH, Lee CH. Endovascular therapy for acute ischemic stroke in patients with active malignancy: a meta-analysis with trial sequential analysis. J Neurointerv Surg 2023; 15:e154-e160. [PMID: 36163348 DOI: 10.1136/jnis-2022-019489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/12/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Active malignancy has a poorer prognosis and more deaths in patients with acute ischemic stroke (AIS). The outcomes of endovascular therapy (EVT) remain controversial in patients with AIS and active malignancy. METHODS We searched PubMed, Cochrane, and Embase for articles published up to June 1, 2022. The primary outcome was good functional outcome at 3 months and successful reperfusion between patients with cancer and AIS and control patients. The secondary and safety outcomes included mortality at 3 months, in-hospital mortality, symptomatic intracerebral hemorrhage (sICH), any ICH, and subarachnoid hemorrhage (SAH). RESULTS Twelve studies involving 5944 patients with AIS secondary to EVT were included (389 patients having active malignancy). The OR of good functional outcome at 3 months was 0.53 (95% CI 0.41 to 0.67) between the two groups. The OR of successful reperfusion between the two groups was 0.90 (95% CI 0.63 to 1.30). Compared with patients without cancers, those with cancers had a higher risk of mortality at 3 months (OR 3.64; 95% CI 2.35 to 6.27) and in-hospital mortality (OR 3.46; 95% CI 1.71 to 7.01). Despite a higher point estimate regarding any ICH (OR 1.41; 95% CI 1.01 to 1.96) and SAH (OR 2.53; 95% CI 1.10 to 5.81), sICH (OR 0.85; 95% CI 0.51 to 1.42) was not significant. CONCLUSION Although a quarter of patients with active malignancy and AIS regained functional independence, physicians and patients should consider whether to apply EVT in patients with active malignancy.
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Affiliation(s)
- Hong-Jie Jhou
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Yu Yang
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Huang Chen
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Cho-Hao Lee
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Mosconi MG, Capponi A, Paciaroni M. Systemic thrombolysis in patients with acute stroke and active cancer: a systematic review and meta-analysis. Intern Emerg Med 2023; 18:1843-1850. [PMID: 37337013 DOI: 10.1007/s11739-023-03312-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 05/11/2023] [Indexed: 06/21/2023]
Abstract
Cancer patients frequently have concomitant cerebrovascular diseases, which significantly worsen their prognosis. Prospective studies validating intravenous thrombolysis (IVT) safety profile in patients with acute ischemic stroke and active cancer are still lacking. Therefore, we aimed to evaluate IVT's efficacy and safety profile in acute ischemic stroke patients with comorbid active cancer. We included in a meta-analysis all relevant published studies, including patients with acute ischemic stroke with or without active cancer and receiving IVT, according to recommendations for IVT treatment for acute ischemic stroke. The primary outcomes were: any intracerebral hemorrhage, all-cause mortality, and good functional outcome reported as modified Rankin Scale (mRS) ≤ 2 at the end of the scheduled follow-up period. We included 11 studies in the meta-analysis. IVT was not associated with a significant increase in the incidence of intracerebral hemorrhage (OR 1.35; 95% CI 0.85-2.14; I2 76%), nor with a significant increase in death for any cause (OR 1.26; 95% CI 0.91-1.75; I2 71%); furthermore, IVT did not influence mRS between cancer and non-active cancer stroke patients (OR 0.72; 95% CI 0.35-1.49; I2 59%). IVT seems safe and effective in patients with ischemic stroke and concomitant cancer. Due to the low overall quality of the evidence, high-quality randomized controlled trials with adequate sample sizes are needed.
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Affiliation(s)
- Maria Giulia Mosconi
- Internal and Vascular and Emergency Medicine-Stroke Unit, Università degli Studi di Perugia/Azienda Ospedaliera Santa Maria della Misericordia, 06129, Perugia, Italy.
| | - Andrea Capponi
- Emergency Department, University of Florence, Florence, Italy
| | - Maurizio Paciaroni
- Internal and Vascular and Emergency Medicine-Stroke Unit, Università degli Studi di Perugia/Azienda Ospedaliera Santa Maria della Misericordia, 06129, Perugia, Italy
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Sun MY, Bhaskar SMM. Bridging the Gap in Cancer-Related Stroke Management: Update on Therapeutic and Preventive Approaches. Int J Mol Sci 2023; 24:ijms24097981. [PMID: 37175686 PMCID: PMC10178058 DOI: 10.3390/ijms24097981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 04/26/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
The underlying aetiopathophysiology of cancer-related strokes and thromboembolisms differs from that of noncancer-related strokes, which makes treating cancer-related strokes and thromboembolisms a distinct clinical challenge. This necessitates the development of novel, individualised diagnostic and treatment strategies. However, limited guidelines are available for the management of cancer-related strokes and the prevention of acute strokes or other thromboembolic events in this patient population. In this article, we present an updated overview of the therapeutic and preventive strategies for strokes in cancer settings. These strategies include acute reperfusion therapy, anticoagulant therapy, antiplatelet therapy, and lifestyle management options. We also outline comprehensive pathways and highlight gaps in the evidence-based clinical management of cancer-related strokes or thromboembolisms. Additionally, future recommendations for the management of strokes in cancer patients are provided.
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Affiliation(s)
- Ming-Yee Sun
- Global Health Neurology Lab, Sydney, NSW 2000, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
- UNSW Medicine and Health, University of New South Wales (UNSW), South Western Sydney Clinical Campuses, Sydney, NSW 2170, Australia
| | - Sonu M M Bhaskar
- Global Health Neurology Lab, Sydney, NSW 2000, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital and South West Sydney Local Health District (SWSLHD), Liverpool, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Stroke and Neurology Research Group, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
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Aboul-Nour H, Maraey A, Jumah A, Khalil M, Elzanaty AM, Elsharnoby H, Al-Mufti F, Chebl AB, Miller DJ, Mayer SA. Mechanical Thrombectomy for Acute Ischemic Stroke in Metastatic Cancer Patients: A Nationwide Cross-Sectional Analysis. J Stroke 2023; 25:119-125. [PMID: 36592967 PMCID: PMC9911847 DOI: 10.5853/jos.2022.02334] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/01/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy (MT) is the standard treatment for large vessel occlusion (LVO) acute ischemic stroke. Patients with active malignancy have an increased risk of stroke but were excluded from MT trials. METHODS We searched the National Readmission Database for LVO patients treated with MT between 2016-2018 and compared the characteristics and outcomes of cancer-free patients to those with metastatic cancer (MC). Primary outcomes were all-cause in-hospital mortality and favorable outcome, defined as a routine discharge to home (regardless of whether home services were provided or not). Multivariate regression was used to adjust for confounders. RESULTS Of 40,537 LVO patients treated with MT, 933 (2.3%) had MC diagnosis. Compared to cancer-free patients, MC patients were similar in age and stroke severity but had greater overall disease severity. Hospital complications that occurred more frequently in MC included pneumonia, sepsis, acute coronary syndrome, deep vein thrombosis, and pulmonary embolism (P<0.001). Patients with MC had similar rates of intracerebral hemorrhage (20% vs. 21%) but were less likely to receive tissue plasminogen activator (13% vs. 23%, P<0.001). In unadjusted analysis, MC patients as compared to cancer-free patients had a higher in-hospital mortality rate and were less likely to be discharged to home (36% vs. 42%, P=0.014). On multivariate regression adjusting for confounders, mortality was the only outcome that was significantly higher in the MC group than in the cancerfree group (P<0.001). CONCLUSION LVO patients with MC have higher mortality and more infectious and thrombotic complications than cancer-free patients. MT nonetheless can result in survival with good outcome in slightly over one-third of patients.
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Affiliation(s)
- Hassan Aboul-Nour
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA,Department of Neurology, Henry Ford Hospital, Detroit, MI, USA,Correspondence: Hassan Aboul-Nour 8th Floor, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, 80 Jesse Hill Jr. Dr. SE, Atlanta, GA 30303, USA Tel: +1-857-316-6739 E-mail:
| | - Ahmed Maraey
- Department of Internal Medicine, CHI St. Alexius Health, Bismark, ND, USA
| | - Ammar Jumah
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Mahmoud Khalil
- Department of Internal Medicine, Lincoln Medical and Mental Health Center, New York, NY, USA
| | - Ahmed M. Elzanaty
- Cardiovascular Medicine Department, University of Toledo, Toledo, OH, USA
| | - Hadeer Elsharnoby
- Department of Internal Medicine, Carle Foundation Hospital, Urbana, IL, USA
| | - Fawaz Al-Mufti
- Departments of Neurology and Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Alex Bou Chebl
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | | | - Stephan A. Mayer
- Departments of Neurology and Neurosurgery, New York Medical College, Valhalla, NY, USA
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Duan L, Fu Z, Zhao H, Song C, Tian Q, Dmytriw AA, Regenhardt RW, Sun Z, Guo X, Wang X, Yang B. Outcomes after endovascular thrombectomy for acute ischemic stroke patients with active cancer: A systematic review and meta-analysis. Front Neurol 2022; 13:992825. [PMID: 36341106 PMCID: PMC9631814 DOI: 10.3389/fneur.2022.992825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/23/2022] [Indexed: 11/23/2022] Open
Abstract
Background Active cancer (AC) is a known risk factor for stroke and a common comorbidity among patients being considered for treatment with endovascular thrombectomy (EVT). This systematic review and meta-analysis aimed to evaluate the current evidence for the feasibility, efficacy, and safety of EVT for patients with AC. Methods MEDLINE, EMBASE, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs) and observational studies which met the inclusion criteria for EVT in patients with AC. Studies were excluded due to the mismatch of data format, article type, and group design. The risk of bias was assessed through different scales according to the study design. I2 statistics were used to evaluate the heterogeneity. Funnel plots were used to evaluate publication bias. Results A total of six studies and 3,657 patients were included. Compared to without active cancer (WC) patients, patients with AC had a significantly higher proportion of in-hospital mortality (OR 3.24; 95% CI, 1.03–10.15). The estimated rate of favorable outcome of six studies was lower in patients with AC than in patients with WC (OR 0.47; 95% CI, 0.35–0.65). For 90-day mortality of four studies, the AC group had a higher proportion when compared with the WC group (OR 3.87; 95% CI, 2.64–5.68). There was no difference between rate of six studies of successful recanalization (OR 1.24; 95% CI, 0.90–1.72) and four studies of symptomatic ICH (OR 1.09; 95% CI, 0.61–1.97) comparing AC and WC. Conclusion Patients with AC are less likely to have a favorable outcome and have a higher risk of mortality after EVT. Further studies are warranted for this unique patient population.
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Affiliation(s)
- Linyan Duan
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Zhaolin Fu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Hengxiao Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Chengyu Song
- Department of Library, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Qiuyue Tian
- Beijing Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China
| | - Adam A. Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Robert W. Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Ziyi Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Xiaofan Guo
- Department of Neurology, Loma Linda University Health, Loma Linda, CA, United States
| | - Xue Wang
- Department of Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bin Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
- *Correspondence: Bin Yang
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Caimano D, Letteri F, Capasso F, Limbucci N, Nencini P, Sarti C, Alemseged F, Bigliardi G, Morotti A, Toni D, Zini A, Arba F. Endovascular treatment in patients with acute ischemic stroke and cancer: Systematic review and meta-analysis. Eur Stroke J 2022; 7:204-211. [PMID: 36082266 PMCID: PMC9446332 DOI: 10.1177/23969873221100897] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/27/2022] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION Although stroke occurs frequently in patients with cancer, there is scarce evidence regarding the safety and efficacy of endovascular treatment (EVT) in patients with acute ischemic stroke and concurrent cancer. We performed a systematic review and meta-analysis to summarize the existing literature. METHODS We searched for English written observational studies reporting data on safety and efficacy of EVT in patients with acute ischemic stroke and concurrent cancer. Outcomes of interest were: functional independence (modified Rankin Scale (mRS) ⩽ 2); mortality at 3 months; rate of successful recanalization (modified Treatment In Cerebral Ischemia (mTICI) 2b or 3); occurrence of any hemorrhagic transformation (both symptomatic and asymptomatic). We pooled data with Maentel-Haenszel model to calculate cumulative odds ratios (ORs). RESULTS We included seven studies with a total of 4465 patients, of whom 262 (6%) with cancer. We observed various definitions of cancer across included studies. Patients with cancer had less likely mRS⩽2 at 3 months (24% vs 42%, OR = 0.44; 95% CI = 0.32-0.60) and increased probability of death (43% vs 19%, OR = 5.02; 95% CI = 2.90-8.69). There was no difference in successful recanalization (70% vs 75%, OR = 0.84; 95% CI = 0.49-1.44); patients with cancer had increased risk of any intracerebral hemorrhage after treatment (49% vs 34%, OR = 1.95; 95% CI = 1.28-2.96), though not for symptomatic ICH (OR 1.04; 95% CI = 0.59-1.85). CONCLUSION Patients with acute ischemic stroke and cancer have similar EVT recanalization but higher probability of functional dependence, death, and any hemorrhagic transformation, though not necessarily symptomatic, compared with patients without cancer. Our results may help communication with patients and carers.
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Affiliation(s)
- Danilo Caimano
- NEUROFARBA Department, University of
Florence, Firenze, Italy
| | | | - Francesco Capasso
- Neurovascular Interventional Unit,
Careggi University Hospital, Firenze, Italy
| | - Nicola Limbucci
- Neurovascular Interventional Unit,
Careggi University Hospital, Firenze, Italy
| | | | - Cristina Sarti
- NEUROFARBA Department, University of
Florence, Firenze, Italy
| | - Fana Alemseged
- Department of Medicine and Neurology,
Royal Melbourne Hospital, University of Melbourne, Australia
| | - Guido Bigliardi
- Neurology Clinic – Stroke Unit,
Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena,
Italy
| | - Andrea Morotti
- Dipartimento di Scienze Neurologiche e
della Visione, Clinica Neurologica, ASST Spedali Civili di Brescia, Brescia,
Italy
| | - Danilo Toni
- Neurological Sciences, University of
Rome La Sapienza, Roma, Italy
| | - Andrea Zini
- Department of Neurology and Stroke
Center, IRCCS Istituto delle Scienze Neurologiche, Maggiore Hospital, Bologna,
Italy
| | - Francesco Arba
- Stroke Unit, Careggi University
Hospital, Firenze, Italy
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10
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Mechanical Thrombectomy for Acute Ischemic Stroke in Patients with Malignancy: A Systematic Review. J Clin Med 2022; 11:jcm11164696. [PMID: 36012933 PMCID: PMC9410462 DOI: 10.3390/jcm11164696] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/02/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Ischemic stroke is a common occurrence in patients with concomitant malignancy. Systemic thrombolysis is often contraindicated in these patients, and mechanical thrombectomy (MT) is the preferred method of intervention. This review aims to collect the available data on the safety and efficacy of MT in cancer patients (CPs).Methods: The PubMed/MEDLINE and SCOPUS databases were systematically searched for studies assessing safety (mortality, intracranial hemorrhage) and efficacy (reperfusion, functional outcome) indices in CPs receiving MT. Potentially relevant parameters examined in solitary studies were also extracted (e.g., stroke recurrence, brain malignancy).Results: A total of 18 retrospective studies of various methodologies and objectives were identified. Rates of in-hospital mortality, intracranial hemorrhage of any kind, reperfusion rates, and discharge condition did not seem to present any considerable differences between CPs and patients without cancer. On the contrary, 90-day mortality was higher and 90-day functional independence was lower in CPs. Three studies on cancer-related stroke (no other identifiable etiology and high D-dimer levels in the presence of active cancer) showed constant tendencies towards unfavorable conditions. Conclusions: Per the available evidence, MT appears to be a safe treatment option for CPs. It is still unclear whether the 90-day mortality and outcome rates are more heavily influenced by the malignancy and not the intervention itself, so MT can be considered in CPs with prospects of a good functional recovery, undertaking an individualized approach.
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Garg A, Chopra S, Starr M, Rocha M, Dawod J, Leira E, Shaban A. In-Hospital Outcomes and Recurrence of Acute Ischemic Stroke in Patients With Solid Organ Malignancy. Neurology 2022; 99:e393-e401. [PMID: 35487697 DOI: 10.1212/wnl.0000000000200601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/10/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The aim of this work was to evaluate the influence of solid organ malignancies on the in-hospital outcomes and recurrent strokes among patients hospitalized with acute ischemic stroke (AIS). METHODS Adult hospitalizations with a primary diagnosis of AIS were identified from the Nationwide Readmissions Database from 2016 to 2018. Logistic regression was used to compare the differences in the use of acute stroke interventions and clinical outcomes in patients with and without malignancy. Survival analysis was used to evaluate the risk of readmission due to recurrent stroke after discharge. RESULTS There were 1,385,840 hospitalizations due to AIS (mean ± SD age 70.4 ± 14.0 years, female 50.2%). Of these, 50,553 (3.7%) had a concurrent diagnosis of solid organ malignancy. The 5 most common malignancies included lung cancer (24.6%), prostate cancer (13.2%), breast cancer (9.3%), pancreatic cancer (6.5%), and colorectal cancer (6.2%). After adjustment for baseline differences, patients with malignancy were more likely to have intraparenchymal hemorrhage (odds ratio [OR] 1.11, 95% CI 1.04-1.19), in-hospital mortality (OR 2.15, 95% CI 2.04-2.28), and discharge disposition other than to home (OR 1.70, 95% CI 1.64-1.75). Patients with malignancy were less likely to receive IV thrombolysis (tissue plasminogen activator [tPA]) and were more likely to undergo mechanical thrombectomy (MT). Among the subgroups of patients treated with tPA or MT, the outcomes were comparable between patients with and without malignancy, except patients with lung cancer remained at a higher risk of mortality and adverse disposition despite these acute stroke interventions. Patients with malignancy were at a higher risk of readmission due to recurrent AIS within 1 year of discharge (hazards ratio 1.18, 95% CI 1.11-1.25), and this risk was driven specifically by the lung and pancreatic cancers. DISCUSSION While patients with malignancy generally have worse in-hospital outcomes compared to those without, there is considerable variation in these outcomes according to the different cancer types and the use of acute stroke interventions. The use of tPA and MT is generally safe for eligible patients with an underlying malignancy. Patients with lung and pancreatic cancers have a higher early risk of recurrent stroke and might need more intensive surveillance and careful institution of the optimal secondary prevention measures.
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Affiliation(s)
- Aayushi Garg
- From the Departments of Neurology (A.G., E.L., A.S.) and Pathology (S.C.), University of Iowa Hospitals and Clinics, Iowa City; and Department of Neurology (M.S., M.R., J.D.), University of Pittsburgh Medical Center, PA.
| | - Saurav Chopra
- From the Departments of Neurology (A.G., E.L., A.S.) and Pathology (S.C.), University of Iowa Hospitals and Clinics, Iowa City; and Department of Neurology (M.S., M.R., J.D.), University of Pittsburgh Medical Center, PA
| | - Matthew Starr
- From the Departments of Neurology (A.G., E.L., A.S.) and Pathology (S.C.), University of Iowa Hospitals and Clinics, Iowa City; and Department of Neurology (M.S., M.R., J.D.), University of Pittsburgh Medical Center, PA
| | - Marcelo Rocha
- From the Departments of Neurology (A.G., E.L., A.S.) and Pathology (S.C.), University of Iowa Hospitals and Clinics, Iowa City; and Department of Neurology (M.S., M.R., J.D.), University of Pittsburgh Medical Center, PA
| | - Judy Dawod
- From the Departments of Neurology (A.G., E.L., A.S.) and Pathology (S.C.), University of Iowa Hospitals and Clinics, Iowa City; and Department of Neurology (M.S., M.R., J.D.), University of Pittsburgh Medical Center, PA
| | - Enrique Leira
- From the Departments of Neurology (A.G., E.L., A.S.) and Pathology (S.C.), University of Iowa Hospitals and Clinics, Iowa City; and Department of Neurology (M.S., M.R., J.D.), University of Pittsburgh Medical Center, PA
| | - Amir Shaban
- From the Departments of Neurology (A.G., E.L., A.S.) and Pathology (S.C.), University of Iowa Hospitals and Clinics, Iowa City; and Department of Neurology (M.S., M.R., J.D.), University of Pittsburgh Medical Center, PA
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12
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Woock M, Martinez-Majander N, Seiffge DJ, Selvik HA, Nordanstig A, Redfors P, Lindgren E, Sanchez van Kammen M, Rentzos A, Coutinho JM, Doyle K, Naess H, Putaala J, Jood K, Tatlisumak T. Cancer and stroke: commonly encountered by clinicians, but little evidence to guide clinical approach. Ther Adv Neurol Disord 2022; 15:17562864221106362. [PMID: 35785404 PMCID: PMC9243376 DOI: 10.1177/17562864221106362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/24/2022] [Indexed: 12/03/2022] Open
Abstract
The association between stroke and cancer is well-established. Because of an aging population and longer survival rates, the frequency of synchronous stroke and cancer will become even more common. Different pathophysiologic mechanisms have been proposed how cancer or cancer treatment directly or via coagulation disturbances can mediate stroke. Increased serum levels of D-dimer, fibrin degradation products, and CRP are more often seen in stroke with concomitant cancer, and the clot retrieved during thrombectomy has a more fibrin- and platelet-rich constitution compared with that of atherosclerotic etiology. Multiple infarctions are more common in patients with active cancer compared with those without a cancer diagnosis. New MRI techniques may help in detecting typical patterns seen in the presence of a concomitant cancer. In ischemic stroke patients, a newly published cancer probability score can help clinicians in their decision-making when to suspect an underlying malignancy in a stroke patient and to start cancer-screening studies. Treating stroke patients with synchronous cancer can be a delicate matter. Limited evidence suggests that administration of intravenous thrombolysis appears safe in non-axial intracranial and non-metastatic cancer patients. Endovascular thrombectomy is probably rather safe in these patients, but probably futile in most patients placed on palliative care due to their advanced disease. In this topical review, we discuss the epidemiology, pathophysiology, and prognosis of ischemic and hemorrhagic strokes as well as cerebral venous thrombosis and concomitant cancer. We further summarize the current evidence on acute management and secondary preventive therapy.
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Affiliation(s)
- Malin Woock
- Department of Neurology, Sahlgrenska University Hospital, Blå stråket 7, 413 46 Gothenburg, Sweden
| | | | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Annika Nordanstig
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Lindgren
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mayte Sanchez van Kammen
- Department of Neurology, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Alexandros Rentzos
- Department of Radiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Karen Doyle
- Department of Physiology, Centre for Research in Medical Devices (CÚRAM), National University of Ireland, Galway, Galway, Ireland
| | - Halvor Naess
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Katarina Jood
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Turgut Tatlisumak
- Department of Clinical Neuroscience, Institute of Neurosciences and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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13
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Mattingly TK, Risco JE, Burch JE, Whyte R, Kohli GS, Susa S, Bhalla T, Bender MT. Endovascular Therapy is Effective for Large Vessel Occlusion Despite Concurrent Cancer. J Stroke Cerebrovasc Dis 2022; 31:106439. [PMID: 35313233 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106439] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/19/2022] [Accepted: 02/23/2022] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Ischemic stroke and concurrent cancer is increasingly recognized. However, optimal management is uncertain. As mechanical thrombectomy has become the standard of care for large vessel occlusion, more patients with cancer are presenting for embolectomy. However, it is unknown whether this subgroup has the same benefit profile described in multiple randomized trials for thrombectomy for large vessel occlusion. Our objective was to retrospectively evaluate a North American embolectomy database for safety and outcomes in patients with active cancer. MATERIALS AND METHODS A case series of 284 embolectomies over 30 months at a single North American stroke center were divided into thrombectomy patients with active cancer(n=25) and those without active cancer (n=259). We compared patient characteristics, procedural characteristics, and procedural outcomes between patients with and without active cancer. Univariate and multivariate analysis of angiographic outcomes, postoperative hemorrhage, and functional outcome was performed. RESULTS Of the 284 thrombectomy cases, 9% were performed on patients with active cancer. Active cancer patients had a similar recanalization grade and post-operative hemorrhage rate, compared to patients without cancer. Active cancer patients had a significantly higher 90 day mortality (40% vs 20%, p=0.018). On multivariate analysis, good functional outcome (mRS 0-2) was not impacted by active cancer. However, when mRS was evaluated as an ordinal shift analysis, worse functional outcome was associated with active cancer (OR 2.98; 95% CI, 1.29 to 6.59), greater age, NIHSS> 10, and ASPECTS<9. CONCLUSIONS This single center retrospective series of active cancer patients undergoing thrombectomy for large vessel occlusion demonstrates similar rates of recanalization, post-operative hemorrhage, and good outcomes. While the active cancer group has a high short-term mortality, the potential to maintain quality of life in the survivors makes thrombectomy reasonable in this patient population. Awareness of ischemic stroke as a complication of cancer and the safety of thrombectomy in this population are important as this population subtype is expected to grow with improved oncology and stroke care.
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Affiliation(s)
- Thomas K Mattingly
- Dept of Neurosurgery, University of Rochester, Rochester, NY. 585-273-1900, United States.
| | - Jorge E Risco
- Dept of Neurology, University of Rochester, Rochester, NY. 585-275-2776, United States
| | - Jaclyn E Burch
- Dept of Neurology, University of Rochester, Rochester, NY. 585-275-2776, United States
| | - Raquel Whyte
- Dept of Neurosurgery, University of Rochester, Rochester, NY. 585-273-1900, United States
| | - Gurkirat S Kohli
- Dept of Neurosurgery, University of Rochester, Rochester, NY. 585-273-1900, United States
| | - Stephen Susa
- Dept of Neurosurgery, University of Rochester, Rochester, NY. 585-273-1900, United States
| | - Tarun Bhalla
- Dept of Neurosurgery, University of Rochester, Rochester, NY. 585-273-1900, United States
| | - Matthew T Bender
- Dept of Neurosurgery, University of Rochester, Rochester, NY. 585-273-1900, United States
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14
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Verschoof MA, Groot AE, de Bruijn SFTM, Roozenbeek B, Bart van der Worp H, Dippel DWJ, Emmer BJ, Roosendaal SD, Majoie CBLM, Roos YBWM, Coutinho JM. Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy. Neurology 2022; 98:e993-e1001. [PMID: 35017306 DOI: 10.1212/wnl.0000000000013316] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 12/28/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explore clinical and safety outcomes of patients with acute ischemic stroke (AIS) and active cancer after endovascular treatment (EVT). METHODS Using data from the MR CLEAN Registry, we compared patients with active cancer (defined as cancer diagnosed within 12 months prior to stroke, metastatic disease, or current cancer treatment) to patients without cancer. Outcomes were 90-day modified Rankin Scale (mRS) score, mortality, successful reperfusion (eTICI scores≥2b), symptomatic intracranial hemorrhage (sICH), and recurrent stroke. Subgroup analyses were performed in patients with a pre-stroke mRS score of 0 or 1 and according to treatment setting (curative or palliative). Analyses were adjusted for prognostic variables. RESULTS Of 2583 patients who underwent EVT, 124 (4.8%) had active cancer. They more often had pre-stroke disability (mRS≥2: 34.1% vs. 16.6%). The treatment setting was palliative in 25.3% of the patients. There was a shift towards worse functional outcome at 90 days in patients with active cancer (adjusted common OR 2.2, 95% CI 1.5-3.2). At 90 days, patients with active cancer were less often independent (mRS 0-2: 22.6% vs. 42.0%, aOR 0.5, 95% CI 0.3-0.8), and more often dead (52.2% vs. 26.5%, aOR 3.2, 95% CI 2.1-4.9). Successful reperfusion (67.8% vs. 60.5%, aOR 1.4, 95% CI 1.0-2.1) and sICH rates (6.5% vs. 5.9%, aOR 1.1, 95 %CI 0.5-2.3) did not differ. Recurrent stroke within 90 days was more common in patients with active cancer (4.0% vs. 1.3%, aOR 3.1, 95% CI 1.2-8.1). The sensitivity analysis of patients with a pre-stroke mRS of 0 or 1 showed that patients with active cancer still had a worse outcome at 90 days (acOR 1.9, 95% CI 1.2-3.0). Patients with active cancer in a palliative treatment setting regained functional independence less often compared to patients in a curative setting (18.2% vs. 32.1%) and mortality was also higher (81.8% vs. 39.3%). CONCLUSIONS Despite similar technical success, patients with active cancer had significantly worse outcomes after EVT for AIS. Moreover, they had an increased risk of recurrent stroke. Nevertheless, about a quarter of the patients regained functional independence and the risk of other complications, most notably sICH, was not increased. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that patients with active cancer undergoing EVT for AIS have worse functional outcomes at 90 days compared to those without active cancer.
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Affiliation(s)
| | - Adrien E Groot
- Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam
| | | | | | | | | | - Bart Jeroen Emmer
- Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - Stefan D Roosendaal
- Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - Yvo B W M Roos
- Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam
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15
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Recanalisation theraphy for acute ischemic stroke in cancer patients. Sci Rep 2021; 11:11634. [PMID: 34079015 PMCID: PMC8172643 DOI: 10.1038/s41598-021-91257-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 05/17/2021] [Indexed: 12/02/2022] Open
Abstract
To date, very few studies focused their attention on efficacy and safety of recanalisation therapy in acute ischemic stroke (AIS) patients with cancer, reporting conflicting results. We retrospectively analysed data from our database of consecutive patients admitted to the Udine University Hospital with AIS that were treated with recanalisation therapy, i.e. intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and bridging therapy, from January 2015 to December 2019. We compared 3-month dependency, 3-month mortality, and symptomatic intracranial haemorrhage (SICH) occurrence of patients with active cancer (AC) and remote cancer (RC) with that of patients without cancer (WC) undergoing recanalisation therapy for AIS. Patients were followed up for 3 months. Among the 613 AIS patients included in the study, 79 patients (12.9%) had either AC (n = 46; 7.5%) or RC (n = 33; 5.4%). Although AC patients, when treated with IVT, had a significantly increased risk of 3-month mortality [odds ratio (OR) 6.97, 95% confidence interval (CI) 2.42–20.07, p = 0.001] than WC patients, stroke-related deaths did not differ between AC and WC patients (30% vs. 28.8%, p = 0.939). There were no significant differences between AC and WC patients, when treated with MT ± IVT, regarding 3-month dependency, 3-month mortality and SICH. Functional independence, mortality, and SICH were similar between RC and WC patients. In conclusion, recanalisation therapy might be used in AIS patients with nonmetastatic AC and with RC. Further studies are needed to explore the outcome of AIS patients with metastatic cancer undergoing recanalisation therapy.
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16
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Pana TA, Mohamed MO, Mamas MA, Myint PK. Prognosis of Acute Ischaemic Stroke Patients with Cancer: A National Inpatient Sample Study. Cancers (Basel) 2021; 13:cancers13092193. [PMID: 34063601 PMCID: PMC8125286 DOI: 10.3390/cancers13092193] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/25/2021] [Accepted: 04/28/2021] [Indexed: 12/20/2022] Open
Abstract
Whilst cancer is a risk factor for acute ischaemic stroke (AIS), its impact on AIS prognosis between metastatic and non-metastatic (MC and NMC) disease is poorly understood. Furthermore, the receipt of intravenous thrombolysis (IVT) and endovascular thrombectomy (ET) and their outcomes is poorly researched. AIS admissions from the National Inpatient Sample (NIS) were included (October 2015-December 2017). Multivariable logistic regressions adjusting for a wide range of confounders analysed the relationship between NMC and MC and AIS in-hospital outcomes (mortality, prolonged hospitalisation >4 days and routine home discharge). Interaction terms with IVT and ET were also computed to explore their impact amongst cancer patients. A total of 221,249 records representative of 1,106,045 admissions were included. There were 38,855 (3.51%) AIS admissions with co-morbid cancer: NMC = 53.78% and MC = 46.22%. NMC was associated with 23% increased odds of in-hospital mortality (odds ratio (95% confidence interval) = 1.23 (1.07-1.42)), which was mainly driven by pancreatic and respiratory cancers. This association was entirely offset by both IVT and ET. MC was associated with two-fold increased odds of in-hospital mortality (2.16 (1.90-2.45)), which was mainly driven by respiratory, pancreatic and colorectal cancers. This association was only offset by ET. Both NMC and MC were significantly associated with prolonged hospitalisation and decreased odds of routine discharge. Cancer patients are at higher odds of acute adverse outcomes after AIS and warrant robust primary prevention. IVT and ET improve these outcomes and should thus be offered routinely unless otherwise contraindicated in this group of stroke patients.
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Affiliation(s)
- Tiberiu A. Pana
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent ST4 6QG, UK; (M.O.M.); (M.A.M.); (P.K.M.)
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Correspondence:
| | - Mohamed O. Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent ST4 6QG, UK; (M.O.M.); (M.A.M.); (P.K.M.)
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent ST4 6QG, UK; (M.O.M.); (M.A.M.); (P.K.M.)
| | - Phyo K. Myint
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent ST4 6QG, UK; (M.O.M.); (M.A.M.); (P.K.M.)
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
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17
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Yoo J, Kim YD, Park H, Kim BM, Bang OY, Kim HC, Han E, Kim DJ, Heo J, Kim M, Choi JK, Lee KY, Lee HS, Shin DH, Choi HY, Sohn SI, Hong JH, Lee JY, Baek JH, Kim GS, Seo WK, Chung JW, Kim SH, Song TJ, Han SW, Park JH, Kim J, Jung YH, Cho HJ, Ahn SH, Lee SI, Seo KD, Heo JH, Nam HS. Immediate and Long-Term Outcomes of Reperfusion Therapy in Patients With Cancer. Stroke 2021; 52:2026-2034. [PMID: 33910369 DOI: 10.1161/strokeaha.120.032380] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Joonsang Yoo
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Yongin Severance Hospital (J.Y., J.K.), Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
| | - Hyungjong Park
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea (H.P., S.-I.S., J.-H.H.)
| | - Byung Moon Kim
- Department of Radiology (B.M.K., D.J.K.), Yonsei University College of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (O.Y.B., W.-K.S., J.-W.C.)
| | - Hyeon Chang Kim
- Department of Preventive Medicine (H.C.K.), Yonsei University College of Medicine, Seoul, Korea
| | - Euna Han
- College of Pharmacy, Yonsei Institute for Pharmaceutical Research, Yonsei University, Incheon, South Korea (E.H.)
| | - Dong Joon Kim
- Department of Radiology (B.M.K., D.J.K.), Yonsei University College of Medicine, Seoul, Korea
| | - Joonnyung Heo
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
| | - Minyoung Kim
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyo Choi
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Severance Institute for Vascular and Metabolic Research (K.-Y.L., Y.H.J.), Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Department of Research Affairs (H.S.L.), Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hoon Shin
- Department of Neurology, Gachon University Gil Medical Center, Incheon, Korea (D.H.S.)
| | - Hye-Yeon Choi
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea (H.-Y.C.)
| | - Sung-Il Sohn
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea (H.P., S.-I.S., J.-H.H.)
| | - Jeong-Ho Hong
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea (H.P., S.-I.S., J.-H.H.)
| | - Jong Yun Lee
- Department of Neurology, National Medical Center, Seoul, Korea (J.Y.L., J.-H.B.)
| | - Jang-Hyun Baek
- Department of Neurology, National Medical Center, Seoul, Korea (J.Y.L., J.-H.B.).,Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (J.-H.B.)
| | - Gyu Sik Kim
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea (G.S.K., K.-D.S.)
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (O.Y.B., W.-K.S., J.-W.C.)
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (O.Y.B., W.-K.S., J.-W.C.)
| | - Seo Hyun Kim
- Department of Neurology, Yonsei University Wonju College of Medicine, Korea (S.H.K.)
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, College of Medicine, Ewha Woman's University, Korea (T.-J.S.)
| | - Sang Won Han
- Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea (S.W.H., J.H.P.)
| | - Joong Hyun Park
- Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea (S.W.H., J.H.P.)
| | - Jinkwon Kim
- Department of Neurology, Yongin Severance Hospital (J.Y., J.K.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam, Korea (J.K.)
| | - Yo Han Jung
- Department of Neurology, Gangnam Severance Hospital, Severance Institute for Vascular and Metabolic Research (K.-Y.L., Y.H.J.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Changwon Fatima Hospital, Korea (Y.H.J.)
| | - Han-Jin Cho
- Department of Neurology, Pusan National University School of Medicine, Busan, Korea (H.-J.C.)
| | - Seong Hwan Ahn
- Department of Neurology, Chosun University School of Medicine, Gwangju, Korea (S.H.A.)
| | - Sung Ik Lee
- Department of Neurology, Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea (S.I.L., K.-D.S.)
| | - Kwon-Duk Seo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea (G.S.K., K.-D.S.).,Department of Neurology, Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea (S.I.L., K.-D.S.)
| | | | - Hyo Suk Nam
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
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Eun MY, Jeon ET, Seo KD, Lee D, Jung JM. Reperfusion Therapy in Acute Ischemic Stroke with Active Cancer: A Meta-Analysis Aided by Machine Learning. J Stroke Cerebrovasc Dis 2021; 30:105742. [PMID: 33780696 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105742] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/06/2021] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES While the prevalence of active cancer patients experiencing acute stroke is increasing, the effects of active cancer on reperfusion therapy outcomes are inconclusive. Thus, we aimed to compare the safety and outcomes of reperfusion therapy in acute stroke patients with and without active cancer. MATERIALS AND METHODS A comprehensive literature search was conducted for studies comparing the effects of intravenous thrombolysis (IVT) or endovascular treatment (EVT) in ischemic stroke patients with and without active cancer. The literature was screened using both a manual and machine learning algorithm approach. The outcomes evaluated were symptomatic intracerebral hemorrhage (sICH), all-type intracerebral hemorrhage (aICH), successful recanalization, favorable outcomes (modified Rankin Scale, 0-2), and mortality. We calculated the pooled odds ratio (OR) and 95% confidence interval (CI) using the random-effects model from the included studies. RESULTS Seven studies were analyzed in this meta-analysis. IVT (n = 1012) was associated with an increased risk of sICH (OR, 9.80; 95% CI, 3.19-30.13) in the active cancer group. However, no significant differences in aICH, favorable outcomes, and mortality were found between groups. Although sICH and successful recanalization in the EVT group (n = 2496) were similar, we observed fewer favorable outcomes (OR, 0.55; 95% CI, 0.33-0.93) and a high prevalence of mortality (OR, 2.91; 95% CI, 1.89-4.47) in the active cancer group. CONCLUSIONS Reperfusion therapy may benefit selected patients with acute ischemic stroke with active cancer, considering the comparable clinical outcomes of IVT and procedure-related outcomes of EVT. These results should be cautiously interpreted and confirmed in future well-designed large-scale studies.
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Affiliation(s)
- Mi-Yeon Eun
- Department of Neurology, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea.
| | - Eun-Tae Jeon
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, South Korea; Medical Science Research Center, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, South Korea.
| | - Kwon-Duk Seo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, South Korea.
| | - Dongwhane Lee
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, South Korea.
| | - Jin-Man Jung
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, South Korea; Korea University Zebrafish Translational Medical Research Center, Ansan, South Korea.
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Lee EJ, Bae J, Jeong HB, Lee EJ, Jeong HY, Yoon BW. Effectiveness of mechanical thrombectomy in cancer-related stroke and associated factors with unfavorable outcome. BMC Neurol 2021; 21:57. [PMID: 33549056 PMCID: PMC7866628 DOI: 10.1186/s12883-021-02086-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/25/2021] [Indexed: 11/20/2022] Open
Abstract
Background The effectiveness of mechanical thrombectomy (MT) in cancer-related stroke (CRS) is largely unknown. This study aims to investigate the clinical and radiological outcomes of MT in CRS patients. We also explored the factors that independently affect functional outcomes of patients with CRS after MT. Methods We retrospectively reviewed 341 patients who underwent MT after acute ischemic stroke onset between May 2014 and May 2020. We classified the patients into CRS (n = 34) and control (n = 307) groups and compared their clinical details. Among CRS patients, we analyzed the groups with and without good outcomes (3-months modified Rankin scale [mRS] score 0, 1, 2). Multivariate analysis was performed to investigate the independent predictors of unfavorable outcomes in patients with CRS after MT. Results A total of 341 acute ischemic stroke patients received MT, of whom 34 (9.9%) had CRS. Although the baseline National institute of health stroke scale (NIHSS) score and the rate of successful recanalization was not significantly different between CRS patients and control group, CRS patients showed more any cerebral hemorrhage after MT (41.2% vs. controls 23.8%, p = 0.037) and unfavorable functional outcome at 3 months (CRS patients median 3-month mRS score 4, interquartile range [IQR] 2 to 5.25 vs. controls median 3-month mRS score 3, IQR 1 to 4, [p = 0.026]). In the patients with CRS, elevated serum D-dimer level and higher baseline NIHSS score were independently associated with unfavorable functional outcome at 3 months (adjusted odds ratio [aOR]: 1.524, 95% confidence interval [CI]: 1.043–2.226; aOR: 1.264, 95% CI: 1.010–1.582, respectively). Conclusions MT is an appropriate therapeutic treatment for revascularization in CRS patients. However, elevated serum D-dimer levels and higher baseline NIHSS scores were independent predictors of unfavorable outcome. Further research is warranted to evaluate the significance of these predictors.
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Affiliation(s)
- Eung-Joon Lee
- Department of Neurology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jeonghoon Bae
- Department of Neurology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hae-Bong Jeong
- Department of Neurology, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Eun Ji Lee
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Han-Yeong Jeong
- Department of Neurology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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Endovascular Therapy of Acute Ischemic Stroke in Patients with Large-Vessel Occlusion Associated with Active Malignancy. J Stroke Cerebrovasc Dis 2020; 30:105455. [PMID: 33242784 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105455] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/22/2022] Open
Abstract
PURPOSE There is limited data on the effectiveness of endovascular therapy (EVT) in stroke patients with active malignancy. In this study, we investigated the outcome of EVT for acute ischemic stroke for patients with active malignancy compared to those without malignancy. METHODS We selected patients who underwent EVT for acute ischemic stroke between January 2015 and July 2019. Patients were divided into two groups, those with active malignancy (oncology group - OG) and those without (non-oncology group, NOG). RESULTS 300 patients were included in this study. There were 19 EVT procedures (18 patients) in the OG and 285 procedures (282 patients) in the NOG. There was no difference in recanalization success rate (mTICI 2b & 3) between the groups: 94.7% versus 80.9% in OG and NOG respectively (p = 0.13). Success rate using the direct aspiration (ADAPT) technique of EVT was not different between compared groups (42.9% versus 67.7%; p = 0.18). However, when using smaller-caliber aspiration devices, ADAPT was less successful in OG (0.0% versus 64.7%, p < 0.05). There was no difference in recanalization success rate of EVT when using a stent-retriever or combined technique. Patients in the OG had a less favorable functional outcome than in the NOG group (mRS 0-2 at 90-days post event: 22.2% versus 48.2%, p < 0.05) CONCLUSION: The technical success rate of EVT in patients with active malignancy is similar to the general population of stroke patients. Interestingly, the success rate of EVT using the ADAPT technique was lower in the OG when using smaller caliber aspiration devices.
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Jeon Y, Baik SH, Jung C, Kim JY, Kim BJ, Kang J, Bae HJ, Kim JH. Mechanical thrombectomy in patients with acute cancer-related stroke: is the stent retriever alone effective? J Neurointerv Surg 2020; 13:318-323. [PMID: 32586910 DOI: 10.1136/neurintsurg-2020-016144] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/24/2020] [Accepted: 05/27/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND The optimal first-line mechanical thrombectomy (MT) method in cancer-related stroke (CRS) patients with emergent large vessel occlusion (ELVO) remains largely unknown. The aim of this study is to evaluate the efficacy and safety between contact aspiration (CA) first-line thrombectomy and stent retriever (SR) first-line thrombectomy in CRS patients. METHODS Sixty-two CRS patients with ELVO, who underwent MT between January 2013 and October 2019 at our institution, were retrospectively analyzed. Patients were divided into two groups based on the first-line MT method and compared: the CA group (n=28), which included those who received CA alone or combined CA with SR, and the SR group (n=34), which included those who received conventional SR alone. RESULTS Overall, reperfusion was successful in 75.8% (47/62) of CRS patients, and a good clinical outcome at 90 days was observed in 17.7%. The CA group showed a higher rate of successful reperfusion (89.3% vs 64.7%, P=0.025) shorter procedure time (22 vs 42 min; P=0.029), higher rate of first pass effect (35.7% vs 11.8%, P=0.025), and lower number of passes (1 vs 3, P=0.023) when compared with the SR group. The procedural and hemorrhagic complication rates were similar between the CA and SR groups. The first-line contact aspiration (OR 11.624, 95% CI 1.041 to 129.752; P=0.046) was an independent predictor of successful reperfusion. CONCLUSIONS Among patients with CRS, CA - whether alone or in combination with SR - as first-line MT seems to provide more rapid and successful reperfusion when compared with SR.
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Affiliation(s)
- Yejin Jeon
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Sung Hyun Baik
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Jun Yup Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Jihoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Jae Hyoung Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
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