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Pernod G, Cohen A, Mismetti P, Sanchez O, Mahé I. [Translation into French and republication of: "Cancer-related arterial thromboembolic events"]. Rev Med Interne 2024:S0248-8663(24)00703-3. [PMID: 39097502 DOI: 10.1016/j.revmed.2023.11.011] [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: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 08/05/2024]
Abstract
Cancer is associated with a hypercoagulable state and is a well-known independent risk factor for venous thromboembolism, whereas the association between cancer and arterial thromboembolism is less well established. Arterial thromboembolism, primarily defined as myocardial infarction or stroke is significantly more frequent in patients with cancer, independently of vascular risk factors and associated with a three-fold increase in the risk of mortality. Patients with brain cancer, lung cancer, colorectal cancer and pancreatic cancer have the highest relative risk of developing arterial thromboembolism. Antithrombotic treatments should be used with caution due to the increased risk of haemorrhage, as specified in current practice guidelines.
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Affiliation(s)
- Gilles Pernod
- Service de médecine vasculaire, CHU de Grenoble, université Grenoble-Alpes, Grenoble, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - Ariel Cohen
- Service de cardiologie, hôpital Saint-Antoine, hôpital Tenon, Assistance publique-Hôpitaux de Paris, Sorbonne université, Paris, France; Inserm, UMRS 1166, unité de recherche sur les maladies cardiovasculaires et métaboliques, Institut hospitalo-universitaire, Institut de cardiométabolisme et nutrition (ICAN), Sorbonne université, 75013 Paris, France
| | - Patrick Mismetti
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine vasculaire et thérapeutique, hôpital Nord, CHU de Saint-Étienne, Saint-Étienne, France
| | - Olivier Sanchez
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France; Inserm UMR S1140, innovations thérapeutiques en hémostase, université Paris Cité, Paris, France
| | - Isabelle Mahé
- F-CRIN INNOVTE network, Saint-Étienne, France; Inserm UMR S1140, innovations thérapeutiques en hémostase, université Paris Cité, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France
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2
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Erritzøe-Jervild M, Wenstrup J, Hougaard BH, Kruuse C. Diagnosing cancer-associated ischemic stroke: A systematic review of hematological biomarkers. Int J Stroke 2024; 19:622-634. [PMID: 38192106 DOI: 10.1177/17474930241227385] [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] [Indexed: 01/10/2024]
Abstract
BACKGROUND AND AIM Patients suffering from cancer are reported to have an increased risk of ischemic stroke (IS). We aimed to identify cancer-associated biomarkers found to differentiate between IS associated with cancer from those not associated with cancer. SUMMARY OF REVIEW We performed a systematic search of PubMed and EMBASE databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The study is reported in PROSPERO (#CRD42022355129). In total, 5563 papers were screened, of which 49 papers were included. Seven biomarkers were identified which had the potential to differentiate between patients who had cancer or stroke or both conditions. D-dimer was the most frequently monitored biomarker, and high levels were significantly associated with cancer-related strokes in (42/44) studies. Fibrinogen was significantly associated with cancer-related strokes in 11/27 studies. A higher level of C-reactive protein, investigated in 19 studies, was associated with cancer-related strokes, but conclusive multivariate analysis was not performed. Finally, the four cancer-associated antigens CA125, CA153, CA199, and carcinoembryonic antigen were only reported on in three to six studies, respectively. These studies all originated from the Guangxi province in China. CA125 was associated with an increased risk of IS in four of six studies. CONCLUSION Increased D-dimer seems associated with cancer-related IS. CRP may also be a candidate as a cancer-associated stroke biomarker, but this requires further verification. Fibrinogen and the more specific cancer biomarkers have not yet been proven helpful for detecting cancer-related strokes.
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Affiliation(s)
- Mai Erritzøe-Jervild
- Department of Neurology, Neurovascular Research Unit, Copenhagen University Hospital-Herlev Gentofte, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Neuroscience Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jonathan Wenstrup
- Department of Neurology, Neurovascular Research Unit, Copenhagen University Hospital-Herlev Gentofte, Copenhagen, Denmark
- Emergency Medical Services, Copenhagen, Denmark
- Emergency Medical Services, Region Zealand, Denmark
| | | | - Christina Kruuse
- Department of Neurology, Neurovascular Research Unit, Copenhagen University Hospital-Herlev Gentofte, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Neuroscience Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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3
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Pernod G, Cohen A, Mismetti P, Sanchez O, Mahé I. Cancer-related arterial thromboembolic events. Arch Cardiovasc Dis 2024; 117:101-113. [PMID: 38057257 DOI: 10.1016/j.acvd.2023.11.007] [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: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/08/2023]
Abstract
Cancer is associated with a hypercoagulable state and is a well-known independent risk factor for venous thromboembolism, whereas the association between cancer and arterial thromboembolism is less well established. Arterial thromboembolism, primarily defined as myocardial infarction or stroke is significantly more frequent in patients with cancer, independently of vascular risk factors and associated with a three-fold increase in the risk of mortality. Patients with brain cancer, lung cancer, colorectal cancer and pancreatic cancer have the highest relative risk of developing arterial thromboembolism. Antithrombotic treatments should be used with caution due to the increased risk of haemorrhage, as specified in current practice guidelines.
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Affiliation(s)
- Gilles Pernod
- Service de Médecine Vasculaire, Université Grenoble-Alpes, Grenoble, France; F-CRIN INNOVTE network, Saint-Etienne, France.
| | - Ariel Cohen
- Service de cardiologie, hôpital Saint-Antoine, hôpital Tenon, Assistance publique-Hôpitaux de Paris, Sorbonne université, Paris, France; Unité INSERM UMRS 1166 Unité de recherche sur les maladies cardiovasculaires et métaboliques, Institut Hospitalo-Universitaire, Institut de Cardiométabolisme et Nutrition (ICAN), 75013, Sorbonne Université, Paris, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Olivier Sanchez
- Service de pneumologie et de soins intensifs, AP-HP, hôpital européen Georges-Pompidou, Paris, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Isabelle Mahé
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France; F-CRIN INNOVTE network, Saint-Etienne, France
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4
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Rael S, Webb M, Brown RD, Ruff MW, Keser Z, Sener U. Safety of intravenous thrombolysis for ischemic stroke in patients with hematologic malignancies: A single institution experience. J Stroke Cerebrovasc Dis 2023; 32:107294. [PMID: 37562180 PMCID: PMC10530002 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107294] [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: 04/12/2023] [Revised: 07/13/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Data on safety of thrombolysis for acute ischemic stroke (AIS) in patients with hematologic malignancy is not well established. We report our single institution experience with thrombolysis in this patient population. METHODS We identified patients with pathology-confirmed hematologic malignancy from 2000-2022. Primary exposure was presence of AIS and receipt of intravenous (IV) thrombolysis. Primary outcome was safety of IV thrombolysis in this patient population. Safety was measured through imaging review for hemorrhagic transformation, post-stroke mortality, and modified Rankin Scale (mRS) at 90 days. RESULTS Among 45,894 patients with hematologic malignancy, 1,099 (2.4%) were identified as having a suspected AIS. Twenty (1.8%) received IV tissue plasminogen activator (tPA) for AIS, three underwent endovascular intervention, and 17 had AIS confirmed on MRI. Two patients with confirmed AIS experienced hemorrhagic transformation, one of which was symptomatic. Most patients (n=10, 59%) were functionally independent (mRS 0-2) at 90 days post-stroke, including all patients with active hematologic malignancy at the time of stroke (n=3). Four patients died within 90 days of AIS. None of these deaths were patients with active hematologic malignancy at the time of stroke. CONCLUSIONS Without other contraindications, IV alteplase should be considered for management of AIS in patients with hematologic malignancy. The safety profile of tPA administration in this patient population may be similar to the general population, whether underlying hematologic malignancy is active or in remission.
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Affiliation(s)
- Sofia Rael
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Mason Webb
- Department of Hematology and Oncology, Mayo Clinic, Rochester, MN, USA
| | - Robert D Brown
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Michael W Ruff
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Zafer Keser
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Ugur Sener
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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5
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Zuber M. Stroke and cancer. Rev Neurol (Paris) 2023; 179:417-424. [PMID: 37024364 DOI: 10.1016/j.neurol.2023.03.009] [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: 02/21/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 04/08/2023]
Abstract
Association between stroke and cancer is well-established and has led to a growing literature over the past decades. Risk of ischemic and hemorrhagic stroke is increased among patients with newly diagnosed cancer and 5-10% of stroke patients bear an active cancer. All cancers are concerned, but hematological malignancy in childhood and adenocarcinoma from lung, digestive tract and pancreas in adults are most usually identified. Unique stroke mechanisms are dominated by hypercoagulation, a condition that may lead to both arterial and venous cerebral thromboembolism. Direct tumor effects, infections and therapies may also play some active role in stroke happening. Magnetic Resonance Imaging (MRI) is helpful in: i) detecting typical patterns of ischemic stroke in cancer patients (i.e. concomitant strokes in multiple arterial territories); ii) distinguishing spontaneous intracerebral hemorrhage from tumor bleeding. Recent literature suggests that acute treatment using intravenous thrombolysis is safe in non-metastatic cancer patients. First results from endovascular procedures are reassuring, although arterial reobstruction is more frequent than in cancer-free patients. Prognosis is worse in patients with compared to those without cancer and mostly depends upon several predictors such as the initial stroke severity and the presence of metastasis. In the present review, we aim to provide some practical responses to neurologists about the stroke-cancer association, including prevalence, stroke mechanisms, biomarkers indicative for an occult cancer, influence of neoplasia on acute and long-term stroke treatments, and prognosis.
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Affiliation(s)
- M Zuber
- Groupe hospitalier Paris Saint-Joseph, université Paris Cité, Paris, France.
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6
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Puente-Hernandez M, Rivero-de-Aguilar A, Varela-Lema L. Cancer-associated spinal cord infarction: A systematic review and analysis of survival predictors. J Neurol Sci 2023; 446:120580. [PMID: 36764185 DOI: 10.1016/j.jns.2023.120580] [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: 09/28/2022] [Revised: 12/09/2022] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE The association between spinal cord infarction (SCI) and cancer is an infrequent condition but requires an accurate diagnosis to establish the appropriate treatment. Clinical features and prognosis of cancer-associated SCI have never been assessed. The aim of this systematic review is to describe the characteristics and outcomes of patients with cancer-associated SCI. Illustratively, a case of ovarian cancer-related SCI is presented. MATERIAL AND METHODS Two authors independently analysed three different bibliographic databases looking for cancer-associated SCI case reports and case series. Data regarding age, sex, cardiovascular risk factors (CVRF), history of known cancer, infarction localization, spinal cord syndrome, Zalewski criteria classification, mechanism of ischemia, diagnostic tests, treatment and functional outcome were registered. A statistical analysis was carried out to identify factors related to mortality and survival time. RESULTS A total of 48 articles met the inclusion criteria and 52 patients were identified. The median age was 62 years. The most frequent neoplasm was intravascular large B-cell lymphoma. The median survival time was 17.4 weeks and the cumulative probability of survival at 12 months was 16.3%. In the group of deceased patients there was a higher proportion of malignant neoplasms than in those who survived (94.7% vs. 5.3%, p < 0.01). There were no statistically significant differences in terms of mortality or survival time depending on age, previously known cancer or CVRF. CONCLUSION Cancer-associated SCI entails a poor outcome. Mortality is increased in patients with malignant neoplasm. No other prognosis factors could be identified.
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Affiliation(s)
| | - Alejandro Rivero-de-Aguilar
- Department of Neurology, University Hospital of the Canary Islands, carretera Ofra S/N, La Laguna, Tenerife, Spain
| | - Leonor Varela-Lema
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Praza do Obradoiro, Santiago de Compostela, A Coruña, Spain; Consortium for Biomedical Research in Respiratory Diseases (CIBER de Enfermedades Respiratorias/CibeRes), Av. de Monforte de Lemos 3-5, Madrid, Spain
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Otite FO, Somani S, Aneni E, Akano E, Patel SD, Anikpezie N, Lamikanra O, Masoud H, Latorre JG, Chaturvedi S, Mehndiratta P. Trends in age and sex-specific prevalence of cancer and cancer subtypes in acute ischemic stroke from 2007-2019. J Stroke Cerebrovasc Dis 2022; 31:106818. [PMID: 36323171 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106818] [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: 07/21/2022] [Revised: 09/29/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To describe age and sex-specific prevalence of cancer in acute ischemic stroke (AIS) hospitalizations in the United States over the last decade. METHODS We conducted a retrospective serial cross-sectional study using all primary AIS discharges (weighted n=5,748,358) with and without cancer in the 2007-2019 National Inpatient Sample. Admissions with primary central nervous system cancers were excluded. Joinpoint regression was used to compute the average annualized percentage change (AAPC) in cancer prevalence over time. RESULTS Across the study period, 12.7% of AIS admissions had previous/active cancer, while 4.4% had active cancer. Of these, 18.8% were hematologic cancers, 47.2% were solid cancers without metastasis and 34.0% were metastatic cancers of any type. Age-adjusted active cancer prevalence differed by sex (males:4.8%; females:4.0%) and increased with age up to age 70-79 years (30-39 years 1.4%; 70-79 years:5.7%). Amongst cancer admissions, lung (18.7%) and prostate (17.8%) were the most common solid cancers in men, while lung (19.6%) and breast (13.7%) were the most prevalent in women. Active cancer prevalence increased over time (AAPC 1.7%, p<0.05) but the pace of increase was significantly faster in women (AAPC 2.8%) compared to men (AAPC 1.1%) (p-comparison =0.003). Fastest pace of increased prevalence was seen for genitourinary cancers in women and for gastrointestinal cancers in both sexes. Genitourinary cancers in men declined over time (AAPC -2.5%, p<0.05). Lung cancer prevalence increased in women (AAPC 1.8%, p<0.05) but remained constant in men. Prevalence of head/neck, skin/bone, gastrointestinal, hematological and metastatic cancers increased over time at similar pace in both sexes. CONCLUSION Prevalence of cancer in AIS admissions increased in the US over the last decade but the pace of this increase was faster in women compared to men. Gastrointestinal cancers in both sexes and genitourinary cancers in women are increasing at the fastest pace. Additional studies are needed to determine whether this increase is from co-occurrence or causation of AIS by cancer.
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Affiliation(s)
- Fadar Oliver Otite
- Department of Neurology, State University of New York, Upstate Medical University, Syracuse, NY, USA.
| | - Sana Somani
- Department of Neurology, Georgetown University School of Medicine, Washington, D.C., USA
| | - Ehimen Aneni
- Department of Cardiology, Yale University, New Haven, Connecticut, USA
| | - Emmanuel Akano
- Molecular Neuropharmacological Unit, National Institute of Neurological Diseases and Stroke, NINDS, Bethesda, Maryland, USA
| | - Smit D Patel
- Department of Neurosurgery, University of Connecticut, Hartford, Connecticut, USA
| | - Nnabuchi Anikpezie
- Department of Population Health Science, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Hesham Masoud
- Department of Neurology, State University of New York, Upstate Medical University, Syracuse, NY, USA
| | - Julius Gene Latorre
- Department of Neurology, State University of New York, Upstate Medical University, Syracuse, NY, USA
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore, USA
| | - Prachi Mehndiratta
- Department of Neurology, University of Maryland School of Medicine, Baltimore, USA
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8
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Turner M, Murchie P, Derby S, Ong AY, Walji L, McLernon D, Macleod MJ, Adam R. Is stroke incidence increased in survivors of adult cancers? A systematic review and meta-analysis. J Cancer Surviv 2022; 16:1414-1448. [PMID: 34739710 PMCID: PMC9630245 DOI: 10.1007/s11764-021-01122-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/13/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Existing research hints that people living with and beyond cancer are at an increased risk of stroke. However, there is insufficient evidence to appropriately inform guidelines for specific stroke prevention or management for cancer patients. We conducted a systematic review and meta-analysis to describe and quantify stroke incidence in people living with and beyond cancer. METHODS Medline, CINAHL, and EMBASE were searched for epidemiological studies comparing stroke incidence between cancer and non-cancer patients. Reviewers independently extracted data; random-effects meta-analyses and quality assessment were performed. RESULTS Thirty-six studies were narratively synthesised. Meta-analysis was conducted using seven studies. Methodological quality was high for most studies. Study populations were heterogeneous, and the length of follow-up and risk factors varied. There was a variation in risk between different cancer types and according to stroke type: pancreatic (HR 2.85 (95% CI 2.43-3.36), ischaemic) (HR 2.28 (95% CI 1.43-3.63), haemorrhagic); lung (HR 2.33 (95% CI 1.63-3.35), ischaemic) (HR 2.14 (95% CI 1.45-3.15), haemorrhagic); and head and neck (HR 1.54 (95% CI 1.40-1.69), haemorrhagic) cancers were associated with significantly increased incidence of stroke. Risk is highest within the first 6 months of diagnosis. Narrative synthesis indicated that several studies also showed significantly increased incidence of stroke in individuals with colorectal cancer, breast cancer, ovarian cancer, nasopharyngeal cancer, leukaemia, and myeloma, and those who have received radiotherapy for head and neck cancers and platinum-based chemotherapy may also have higher stroke incidence. CONCLUSIONS Stroke incidence is significantly increased after diagnosis of certain cancers. IMPLICATIONS FOR CANCER SURVIVORS Cardiovascular risk should be assessed during cancer survivorship care, with attention to modifying shared cancer/cardiovascular risk factors.
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Affiliation(s)
- Melanie Turner
- Institute of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK.
| | - Peter Murchie
- Institute of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Sarah Derby
- Institute of Cancer Sciences, University of Glasgow, Wolfson Wohl Cancer Research Centre, Bearsden, Glasgow, G61 1BD, UK
| | - Ariel Yuhan Ong
- Oxford Eye Hospital, Level Lg1 John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Lauren Walji
- University of Aberdeen Medical School, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - David McLernon
- Institute of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Mary-Joan Macleod
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Rosalind Adam
- Institute of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK
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9
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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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10
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Beyeler M, Birner B, Branca M, Meinel T, Vynckier J, Buffle E, Scutelnic A, Heldner MR, Bücke P, Seiffge D, Mordasini P, Dobrocky T, Piechowiak EI, Kaesmacher J, Gralla J, Mattle HP, Arnold M, Fischer U, Pabst T, Berger MD, Jung S. Development of a score for prediction of occult malignancy in stroke patients (occult-5 score). J Stroke Cerebrovasc Dis 2022; 31:106609. [PMID: 35753093 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106609] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/08/2022] [Accepted: 06/16/2022] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Malignancy associated acute ischemic stroke (AIS) requires specific diagnostic work-up, treatment and prevention to improve outcome. This study aimed to develop a biomarker-based score for prediction of occult malignancy in AIS patients. METHODS Single-center cross-sectional study including consecutive AIS patients treated between July 2017 and November 2018. Patients with active malignancy at presentation, or diagnosed within 1 year thereafter and patients free of malignancy, were included and malignancy associated biomarkers were assessed. LASSO analyses of logistic regression were performed to determine biomarkers predictive of active malignancy. Predictors were derived from a predictive model for active malignancy. A comparison between known and unknown (=occult) malignancies when the index stroke occurred was used to eliminate variables not associated with occult malignancy. A predictive score (OCCULT-5 score) for occult malignancy was developed based on the remaining variables. RESULTS From 1001 AIS patients, 61 (6%) presented an active malignancy. Thirty-nine (64%) were known and 22 (36%) occult. Five variables were included in the final OCCULT-5 score: age ≥ 77 years, embolic stroke of undetermined source, multi-territorial infarcts, D-dimer levels ≥ 820 µ/gL, and female sex. A score of ≥ 3 predicted an underlying occult malignancy with a sensitivity of 64%, specificity of 73%, positive likelihood ratio of 2.35 and a negative likelihood ratio of 0.50. CONCLUSIONS The OCCULT-5 score might be useful to identify patients with occult malignancy. It may thus contribute to a more effective and timely treatment and thus lead to a positive impact on overall outcome.
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Affiliation(s)
- Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Switzerland.
| | - Barbara Birner
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | | | - Thomas Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Jan Vynckier
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland; Department of Neurology, Onze Lieve Vrouwziekenhuis Hospital, Aalst, Belgium
| | - Eric Buffle
- ARTORG Center, University of Bern, Bern, Switzerland; Department of Cardiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Pascale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Eike I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Heinrich P Mattle
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland; Neurology Department, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Martin D Berger
- Department of Medical Oncology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
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11
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Willems RA, Winckers K, Biesmans C, de Vos-Geelen J, ten Cate H. Evolving data on cardiovascular complications in cancer. Thromb Res 2022; 213 Suppl 1:S87-S94. [DOI: 10.1016/j.thromres.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/18/2021] [Accepted: 01/03/2022] [Indexed: 11/25/2022]
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12
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Chen S, Zhang J, Lu X, Cen G, Song Y, Deng X, Xie Y, Liu L, Liu Q, Huang J, Li J, Yang H, Shi S, Pan L, Liang Z. Cancer Related Subarachnoid Hemorrhage: A Multicenter Retrospective Study Using Propensity Score Matching Analysis. Front Cell Neurosci 2022; 16:813084. [PMID: 35197827 PMCID: PMC8859848 DOI: 10.3389/fncel.2022.813084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 01/11/2022] [Indexed: 12/22/2022] Open
Abstract
Objective To investigate the clinical features, risk factors and underlying pathogenesis of cancer related subarachnoid hemorrhage (SAH). Methods Clinical data of SAH in patients with active cancer from January 2010 to December 2020 at four centers were retrospectively reviewed. Patients with active cancer without SAH were matched to SAH patients with active cancer group. Logistic regression was applied to investigate the independent risk factors of SAH in patients with active cancer, after a 1:1 propensity score matching (PSM). A receiver operator characteristic curve was configured to calculate the optimal cut-off value of the joint predictive factor for cancer related SAH. Results A total of 82 SAH patients with active cancer and 309 patients with active cancer alone were included. Most SAH patients with cancer had poor outcomes, with 30-day mortality of 41.5%, and with 90-day mortality of 52.0%. The PSM yielded 75 pairs of study participants. Logistic regression revealed that a decrease in platelet and prolonged prothrombin time were the independent risk factors of cancer related SAH. In addition, receiver operator characteristic curve of the joint predictive factor showed the largest AUC of 0.8131, with cut-off value equaling to 11.719, with a sensitivity of 65.3% and specificity of 89.3%. Conclusion Patients with cancer related SAH often have poor outcomes. The decrease in platelet and prolonged prothrombin time are the independent risk factors of cancer related SAH, and the joint predictive factor with cutoff value equal to 11.719 should hence serve as a novel biomarker of cancer related SAH.
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Affiliation(s)
- Shijian Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jian Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xianfu Lu
- Department of Neurology, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Gengyu Cen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yiting Song
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xuhui Deng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yiju Xie
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liuyu Liu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Qianqian Liu
- Department of Neurology, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Junling Huang
- Department of Neurology, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Jing Li
- Department of Neurology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, China
| | - Hong Yang
- Department of Neurology, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Shengliang Shi
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liya Pan
- Department of Neurology, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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13
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Liu Y, Lu L, Cheng X, Qin Q, Wei Y, Wang D, Li H, Li G, Liang H, Li S, Liang Z. The Index of Esophageal Cancer Related Ischemic Stroke: A Retrospective Patient Control Study. Neuropsychiatr Dis Treat 2022; 18:477-485. [PMID: 35264850 PMCID: PMC8900636 DOI: 10.2147/ndt.s355878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/18/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To investigate independent risk factors for esophageal cancer-related ischemic stroke (ECIS) and to use them to develop an index of ECIS to help clinicians identify patients at high risk for ECIS or to identify ECIS from other types of ischemic stroke. METHODS We retrospectively enrolled active esophageal cancer (EC) patients with acute ischemic stroke (ECIS group) and patients with active EC without ischemic stroke (EC group), age- and sex-matched with ECIS patients, at seven centers from January 2011 to December 2020. Clinical data and laboratory and imaging findings were collected. Univariate and multivariate analyses were performed to analyze the independent risk factors for ECIS. Optimal cutoffs for sensitivities and specificities were obtained by Youden's J statistic following a receiver operator characteristic (ROC) analysis of each risk factor and the product of the risk factors. RESULTS A total of 91 ECIS patients and 91 EC patients were included. Elevated levels of carcinoembryonic antigen (CEA) [odds ratio (OR) = 0.105, 95% confidence interval (CI): 1.051-1.174, P < 0.001], D-dimer (DD) (OR = 0.003, 95% CI: 1.002-1.004, P < 0.001), and neutrophil count (OR = 0.857, 95% CI: 1.628-3.407, P < 0.001) were independent risk factors for ECIS. The area under the curve (AUC) of each independent risk factor and the product of the three independent risk factors were calculated by a receiver operator characteristic (ROC) curve, and the cutoff value from the largest AUC was called the ECIS index. CONCLUSION It was suggested that elevated plasma DD and CEA levels and increased neutrophils in EC patients may altogether contribute to the development of ECIS. The index of ECIS may facilitate clinicians to identify patients at high risk for ECIS or to identify ECIS from other etiologic types of ischemic stroke.
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Affiliation(s)
- Yayuan Liu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, People's Republic of China
| | - Lizhi Lu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, People's Republic of China
| | - Xuemin Cheng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, People's Republic of China
| | - Qixiong Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, People's Republic of China
| | - Yunfei Wei
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, 530007, Guangxi Province, People's Republic of China
| | - Dacheng Wang
- Department of Neurology, The Ninth Affiliated Hospital of Guangxi Medical University, Beihai, 536000, Guangxi Province, People's Republic of China
| | - Haihua Li
- Department of Neurology, Fusui County People's Hospital, Chongzuo, 532100, Guangxi Province, People's Republic of China
| | - Guohui Li
- Department of Neurology, Wuzhou Red Cross Hospital, Wuzhou, 543002, Guangxi Province, People's Republic of China
| | - Hongbin Liang
- Department of Neurology, Cenxi People's Hospital, Cenxi, 543200, Guangxi Province, People's Republic of China
| | - Shengyu Li
- Department of Neurology, The Affiliated Wuming Hospital of Guangxi Medical University, Nanning, 530100, Guangxi Province, People's Republic of China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, People's Republic of China
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14
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Kikuno M, Ueno Y, Takekawa H, Kanemaru K, Shimizu T, Kuriki A, Tateishi Y, Doijiri R, Shimada Y, Yamaguchi E, Koga M, Kamiya Y, Ihara M, Tsujino A, Hirata K, Hasegawa Y, Aizawa H, Hattori N, Urabe T. Distinction in Prevalence of Atherosclerotic Embolic Sources in Cryptogenic Stroke With Cancer Status. J Am Heart Assoc 2021; 10:e021375. [PMID: 34689573 PMCID: PMC8751843 DOI: 10.1161/jaha.120.021375] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Cerebrovascular diseases are common comorbidities in patients with cancer. Although active cancer causes ischemic stroke by multiple pathological conditions, including thromboembolism attributable to Trousseau syndrome, the relationship between stroke and inactive cancer is poorly known. The aim of this study was to elucidate the different underlying pathogeneses of cryptogenic stroke in active and inactive patients with cancer, with detailed investigation by transesophageal echocardiography. Methods and Results CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for Embolic Stroke of Undetermined Source/Cryptogenic Stroke) registry is a multicenter registry including data of patients initially diagnosed as having cryptogenic stroke and undergoing transesophageal echocardiography. Patients were divided into active cancer, inactive cancer, and noncancer groups, and their clinical features were compared. Of the total 667 enrolled patients (age, 68.7±12.8 years; 455 men), 41 (6.1%) had active cancer, and 51 (7.5%) had a history of inactive cancer. On multinomial logistic regression analysis, infarctions in multiple vascular territories (odds ratio [OR], 2.73; 95% CI, 1.39–5.40) and CRP (C‐reactive protein) (OR, 1.10; 95% CI, 1.01–1.19) were independently associated with active cancer, whereas age (OR, 1.05; 95% CI, 1.01–1.08), contralateral carotid stenosis from the index stroke lesion (OR, 4.05; 95% CI, 1.60–10.27), calcification of the aortic valve (OR, 2.10; 95% CI, 1.09–4.05), and complicated lesion of the aortic arch (OR, 2.13; 95% CI, 1.11–4.10) were significantly associated with inactive cancer. Conclusions Patients with cancer were not rare in cryptogenic stroke. Although patients with active cancer had more multiple infarctions, patients with inactive cancer had more atherosclerotic embolic sources potentially causing arteriogenic strokes. Registration URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000032957.
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Affiliation(s)
- Muneaki Kikuno
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan.,Department of Neurology Tokyo Medical University Hospital Tokyo Japan
| | - Yuji Ueno
- Department of Neurology Juntendo University Faculty of Medicine Tokyo Japan
| | | | - Kodai Kanemaru
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan.,Department of Neurology Tokyo Medical University Hospital Tokyo Japan
| | - Takahiro Shimizu
- Department of Neurology St. Marianna University School of Medicine Kanagawa Japan
| | - Ayako Kuriki
- Department of Neurology Showa University Koto Toyosu Hospital Tokyo Japan
| | - Yohei Tateishi
- Department of Neurology and Strokology Nagasaki University Hospital Nagasaki Japan
| | - Ryosuke Doijiri
- Department of Neurology Iwate Prefectural Central Hospital Iwate Japan
| | - Yoshiaki Shimada
- Department of Neurology Juntendo University Urayasu Hospital Chiba Japan
| | - Eriko Yamaguchi
- Department of Neurology Iwate Prefectural Central Hospital Iwate Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
| | - Yuki Kamiya
- Department of Neurology Showa University Koto Toyosu Hospital Tokyo Japan
| | - Masafumi Ihara
- Department of Neurology National Cerebral and Cardiovascular Center Osaka Japan
| | - Akira Tsujino
- Department of Neurology and Strokology Nagasaki University Hospital Nagasaki Japan
| | - Koichi Hirata
- Department of Neurology Dokkyo Medical University Tochigi Japan
| | - Yasuhiro Hasegawa
- Department of Neurology St. Marianna University School of Medicine Kanagawa Japan
| | - Hitoshi Aizawa
- Department of Neurology Tokyo Medical University Hospital Tokyo Japan
| | - Nobutaka Hattori
- Department of Neurology Juntendo University Faculty of Medicine Tokyo Japan
| | - Takao Urabe
- Department of Neurology Juntendo University Urayasu Hospital Chiba Japan
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15
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Yamaura G, Ito T, Miyaji Y, Ueda N, Nakae Y, Momoo T, Nakano T, Johmura Y, Higashiyama Y, Joki H, Doi H, Takeuchi H, Takahashi T, Koyano S, Yamaguchi S, Yokoyama M, Tanaka F. Therapeutic efficacy of heparin and direct factor Xa inhibitors in cancer-associated cryptogenic ischemic stroke with venous thromboembolism. Thromb Res 2021; 206:99-103. [PMID: 34454242 DOI: 10.1016/j.thromres.2021.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Anticoagulation therapy, especially using heparin or recently developed oral direct factor Xa inhibitors (DiXals), is recommended as first-line treatment for cancer-related venous thromboembolism (VTE). However, the preventive efficacy of these anticoagulants for cancer-associated ischemic stroke is still unknown. We retrospectively investigated the efficacy of subcutaneous unfractionated heparin (UFH) and DiXals for preventing the recurrence of cancer-associated cryptogenic ischemic stroke with VTE. METHODS We retrospectively studied consecutive patients with cancer-associated cryptogenic ischemic stroke and comorbid VTE who received subcutaneous UFH or oral DiXaIs at 9 hospitals. RESULT Fifty-three patients (24 treated with UFH and 29 treated with DiXaIs) were enrolled. Of these, 47 demonstrated systemic metastasis (cancer stage IV). During 30-day follow-up after initiation of anticoagulation therapy, recurrent ischemic stroke was observed in only 1 patient (4%) in the UFH group and in 9 patients (31%) in the DiXal group. The incidence of major bleeding complications was similar between the 2 groups (4% and 10%, respectively). The cumulative risk of ischemic stroke recurrence within 30 days was lower with UFH than with DiXals (competing risk analysis, p = 0.008). In the DiXal group, patients who experienced recurrence showed significantly higher D-dimer levels than those without recurrence. CONCLUSION In patients with cancer-associated cryptogenic ischemic stroke and comorbid VTE, UFH demonstrated a lower rate of recurrent ischemic stroke than DiXaIs, and there were no differences in bleeding risk between the 2 treatments. D-dimer levels at stroke onset increased the risk of recurrence in the DiXal group but not in the UFH group.
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Affiliation(s)
- Genpei Yamaura
- Department of Neurology, Fujisawa City Hospital, 2-6-1 Fujisawa, Fujisawa 251-8550, Japan
| | - Takeshi Ito
- Department of Neurology, Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawanishimachi, Kanagawa-ku, Yokohama 221-0855, Japan
| | - Yosuke Miyaji
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Naohisa Ueda
- Department of Neurology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Yoshiharu Nakae
- Department of Neurology, Saiseikai Yokohamashi Nanbu Hospital, 3-2-10 Konandai, Konan-ku, Yokohama 234-0054, Japan
| | - Takayuki Momoo
- Department of Neurology, Hiratsuka Kyosai Hospital, 9-11 Oiwake, Hiratsuka 254-8502, Japan
| | - Tatsu Nakano
- Department of Neurology and Stroke Medicine, Yokohama Sakae Kyosai Hospital, 132 Katsura-cho, Sakae-ku, Yokohama 247-8581, Japan
| | - Yuji Johmura
- Department of Neurology, Yokohama Minami Kyousai Hospital, 1-21-1 Mutsuurahigashi, Kanazawa-ku, Yokohama 236-0037, Japan
| | - Yuichi Higashiyama
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Hideto Joki
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Hiroshi Doi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Hideyuki Takeuchi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Tatsuya Takahashi
- Department of Neurology, National Hospital Organization Yokohama Medical Center, 3-60-2 Harajuku, Totsuka-ku, Yokohama 245-8575, Japan
| | - Shigeru Koyano
- Department of Neurology, Yokohama Minami Kyousai Hospital, 1-21-1 Mutsuurahigashi, Kanazawa-ku, Yokohama 236-0037, Japan
| | - Shigeki Yamaguchi
- Department of Neurology, Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawanishimachi, Kanagawa-ku, Yokohama 221-0855, Japan
| | - Mutsumi Yokoyama
- Department of Neurology, Fujisawa City Hospital, 2-6-1 Fujisawa, Fujisawa 251-8550, Japan
| | - Fumiaki Tanaka
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
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16
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Lin X, Wang H, Rong X, Huang R, Peng Y. Exploring stroke risk and prevention in China: insights from an outlier. Aging (Albany NY) 2021; 13:15659-15673. [PMID: 34086602 PMCID: PMC8221301 DOI: 10.18632/aging.203096] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 05/11/2021] [Indexed: 01/01/2023]
Abstract
In contrast to the declining trend in most regions worldwide, the incidence of stroke is increasing in China and is leading to an alarming burden for the national healthcare system. In this review, we have generated new insights from this outlier, and we aim to provide new information that will help decrease the global stroke burden, especially in China and other regions sharing similar problems with China. First of all, several unsolved aspects fundamentally accounting for this discrepancy were promising, including the serious situation of hypertension management, underdiagnosis of atrial fibrillation and underuse of anticoagulants, and unhealthy lifestyles (e.g., heavy smoking). In addition, efforts for further alleviating the incidence of stroke were recommended in certain fields, including targeted antiplatelet regimes and protections from cold wave-related stroke. Furthermore, advanced knowledge about cancer-related strokes, recurrent strokes and the status preceding stroke onset that we called stroke-prone status herein, is required to properly mitigate patient stroke risk, and to provide improved outcomes for patients after a stroke has occurred.
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Affiliation(s)
- Xinrou Lin
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hongxuan Wang
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiaoming Rong
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ruxun Huang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ying Peng
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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17
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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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18
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Navi BB, Kasner SE, Elkind MSV, Cushman M, Bang OY, DeAngelis LM. Cancer and Embolic Stroke of Undetermined Source. Stroke 2021; 52:1121-1130. [PMID: 33504187 DOI: 10.1161/strokeaha.120.032002] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
One-quarter to one-third of ischemic strokes have no established mechanism after standard diagnostic evaluation and are classified as embolic stroke of undetermined source (ESUS). Failure of randomized trials to demonstrate a benefit of direct oral anticoagulants over aspirin for the treatment of ESUS as a single homogeneous entity has led to renewed interest by stroke experts to divide ESUS into subgroups. Emerging data suggest that active cancer, which is present in 5% to 10% of patients with ESUS, is a distinct and important subgroup of ESUS with unique clinical characteristics, underlying pathophysiologies, and treatment and prognostic considerations. Furthermore, the prevalence of cancer-related ESUS is expected to increase as patients with cancer, even those with distant metastases, survive longer due to improvements in cancer treatments. In this topical review, we examine the epidemiological link between ESUS and cancer, the clinical features and potential mechanistic underpinnings of ESUS with cancer (with a focus on novel biomarkers and their relationship to recurrent stroke and other thromboembolic events), and the potential treatment strategies for cancer-related ESUS. We include a critical appraisal of existing data and ongoing or planned clinical trials of different antithrombotic approaches. As cancer-related ESUS is a dynamic disease with variable course, we recommend close collaboration between neurologists and oncologists to develop individualized management plans.
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Affiliation(s)
- Babak B Navi
- Clinical and Translational Neuroscience Unit, Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY (B.B.N.).,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY (B.B.N., L.M.D.)
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY (M.S.V.E.)
| | - Mary Cushman
- Division of Hematology and Oncology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington (M.C.)
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.)
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY (B.B.N., L.M.D.)
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19
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Pathophysiology, Mechanism, and Outcome of Ischemic Stroke in Cancer Patients. J Stroke Cerebrovasc Dis 2020; 29:105299. [PMID: 32951960 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105299] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES The purpose of this study is to assess the risk factors, biomarkers of stroke, mechanism, and outcomes of cerebral infarction among cancerous diseases. MATERIALS & METHODS 156 patients presented by acute ischemic stroke were divided into two groups: the first group included 78 ischemic stroke patients associated with different types of cancer and the second group (control group) included 78 ischemic stroke patients not associated with cancer. Both groups were compared regarding the risk factors, previous thrombotic activity, subtypes, biomarkers of stroke, and outcomes. RESULTS Cancer patients presented by acute ischemic stroke were accompanied by a significantly less incidence of diabetes mellitus, hypertension, dyslipidemia, and coronary heart disease, and atrial fibrillation than non-cancer patients (P < 0.001). While, levels of biomarkers of inflammation like erythrocyte sedimentation rate and C-reactive protein, and stroke biomarkers like fibrinogen, and D-dimer, all together were highly elevated in cancerous disease group of patients (P < 0.01). The prevalence of deep vein thrombosis, pulmonary embolism, and myocardial infarction was significantly higher in patients with cancer than in control patients without cancer (P = 0.008, P < 0.01 and P < 0.01 respectively). The most common stroke etiologies were atherosclerosis of large arteries and stroke of undetermined cause in a cancerous group of patients. Cancer patients were accompanied by significant higher mortality rate (P = 0.005), and more disability as determined by mRS (P < 0.005) CONCLUSIONS: Pathophysiology and mechanism of ischemic stroke in cancerous disease patients were due to different risk factors, biomarkers of stroke, and subtypes in comparison with non- cancerous cases.
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Trousseau Syndrome Related Cerebral Infarction: Clinical Manifestations, Laboratory Findings and Radiological Features. J Stroke Cerebrovasc Dis 2020; 29:104891. [PMID: 32807409 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104891] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/30/2020] [Accepted: 04/13/2020] [Indexed: 12/21/2022] Open
Abstract
PURPOSE We summarized the clinical manifestations, laboratory data, and brain MRI of patients with Trousseau syndrome related cerebral infarction and compared them to patients with other types of cerebral infarction. Through our present research, we hope to aid the neurologists in recognizing and diagnosing this syndrome. METHODS A total of 31 patients at our institution were identified with cerebral infarction resulting from Trousseau syndrome. We have also selected the 180 patients who have suffered from cerebral infarction as control groups and these patients were distributed to large-artery atherosclerosis group; cardio-embolism group; small-artery occlusion group, according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. The clinical data and neuroimage of these patients were collected. RESULTS All our 31 cancer patients were confirmed by pathological biopsy to be adenocarcinomas and the most common cancers are gastric and lung cancers. Patients with Trousseau syndrome exhibited high serum carbohydrate antigen CEA, CA 125 and CA 199 levels. Compared to patients with other types of cerebral infarction, patients with Trousseau syndrome had an increased severity and worse prognosis. Besides, patients had the highest mean level of plasma D-dimer. We also found multiple lesions in multiple vascular territories was the most frequent type of DWI patterns in patients of Trousseau syndrome. CONCLUSIONS Trousseau syndrome can progress rapidly and become life-threatening. For patients who developed unexplained cerebral infarction involving multiple arterial territories, with elevated plasma D-dimer and cancer antigens, Trousseau syndrome should always be considered.
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Cheng X, Qin Q, Lu L, Chen C, Wei Y, Wang D, Li H, Li G, Liang H, Li S, Cheng D, Liang Z. The independent risks and specific biomarker of breast cancer-related ischemic stroke. Int J Neurosci 2020; 131:135-143. [PMID: 32083954 DOI: 10.1080/00207454.2020.1733562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM This retrospective study was designed to investigate the independent risks and specific biomarker for breast cancer-related ischemic stroke (BCRS). METHODS Clinical features and laboratory findings were compared between BCRS group and breast cancer group without stroke, and further multivariate analyses were performed to predict independent risks factors for BCRS patients. A receiver operator characteristic (ROC) curve analysis was configured to estimate the diagnostic efficacy of each independent risk and the product of these risks and to obtain the optimal cut-off value of diagnosis, which was termed the BCRS Index. RESULTS BCRS patients had elevated plasma D-dimer and CA153 levels and platelet-to-lymphocyte ratio (PLR), as well as more patients received endocrine therapy (all p < 0.05). Moreover, multivariate analysis revealed that D-dimer levels (odds ratio [OR]: 1.002; 95% confidence interval [CI]: 1.001-1.003; p = 0.000), CA153 levels (OR: 1.005; 95% CI: 1.001-1.008; p = 0.007), PLR (OR: 1.010; 95% CI: 1.004-1.015; p = 0.001), and endocrine therapy (OR: 1.268; 95% CI: 1.087-1.479; p = 0.003) were identified as independent risks of BCRS. Furthermore, ROC analysis displayed that the product of risks had the best diagnostic efficacy, of which the area under the curve was 0.846 ± 0.28. The optimum cut-off point was 2.37 × 106/mL, which was termed the BCRS Index with higher diagnostic accuracy and validity. CONCLUSIONS Endocrine therapy, as well as elevated plasma D-dimer and CA153 levels and PLR values may be independent risks for BCRS. Furthermore, BCRS Index should be served as a novel specific biomarker for BCRS, which is useful to distinguish BCRS for clinicians.
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Affiliation(s)
- Xuemin Cheng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Qixiong Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Lizhi Lu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Chunyong Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Yunfei Wei
- Department of Neurology, The Second Affliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Dacheng Wang
- Department of Neurology, The Ninth Affiliated Hospital of Guangxi Medical University, Beihai, Guangxi, China
| | - Haihua Li
- Department of Neurology, Fusui County People's Hospital, Chongzuo, Guangxi, China
| | - Guohui Li
- Department of Neurology, Wuzhou Red Cross Hospital, Wuzhou, Guangxi, China
| | - Hongbin Liang
- Department of Neurology, Cenxi People's Hospital, Cenxi, Guangxi, China
| | - Shengyu Li
- Department of Neurology, Wuming County People's Hospital, Nanning, Guangxi, China
| | - Daobin Cheng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
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Bang OY, Chung JW, Lee MJ, Seo WK, Kim GM, Ahn MJ. Cancer-Related Stroke: An Emerging Subtype of Ischemic Stroke with Unique Pathomechanisms. J Stroke 2020; 22:1-10. [PMID: 32027788 PMCID: PMC7005348 DOI: 10.5853/jos.2019.02278] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/05/2019] [Indexed: 01/20/2023] Open
Abstract
Systemic cancer and ischemic stroke are common conditions and two of the most frequent causes of death among the elderly. The association between cancer and stroke has been reported worldwide. Stroke causes severe disability for cancer patients, while cancer increases the risk of stroke. Moreover, cancer-related stroke is expected to increase due to advances in cancer treatment and an aging population worldwide. Because cancer and stroke share risk factors (such as smoking and obesity) and treatment of cancer can increase the risk of stroke (e.g., accelerated atherosclerosis after radiation therapy), cancer may accelerate conventional stroke mechanisms (i.e., atherosclerosis, small vessel disease, and cardiac thrombus). In addition, active cancer and chemotherapy may enhance thrombin generation causing stroke related to coagulopathy. Patients with stroke due to cancer-related coagulopathy showed the characteristics findings of etiologic work ups, D-dimer levels, and infarct patterns. In this review, we summarized the frequency of cancer-related stroke among patients with ischemic stroke, mechanisms of stroke with in cancer patients, and evaluation and treatment of cancer-related stroke. We discussed the possibility of cancer-related stroke as a stroke subtype, and presented the most recent discoveries in the pathomechanisms and treatment of stroke due to cancer-related coagulopathy.
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Affiliation(s)
- Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Translational and Stem Cell Research Laboratory on Stroke, Samsung Medical Center, Seoul, Korea
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Ji Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung-Ju Ahn
- Department of Hemato-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
PURPOSE OF REVIEW To review the latest information about the interactions between cancer and cerebrovascular disease. RECENT FINDINGS Additional data support the finding that both ischemic and hemorrhagic stroke are important complications of cancer or its treatment. Reperfusion therapy is being given successfully to patients with stroke complicating cancer. Hemorrhagic stroke may occur with metastatic disease to the brain, coagulopathies from cancer, in particular leukemia, or as complications of chemotherapy. Ischemic stroke also may be a complication of metastatic disease with local invasion of vessels, a pro-thrombotic disorder such as non-bacterial thrombotic endocarditis (NBTE) or disseminated intravascular coagulation (DIC), or secondary to chemotherapy. Stroke also is a potential consequence of radiation therapy to the head and neck. Venous sinus thrombosis may develop with hematologic malignancies or chemotherapy. Although many patients will have a history of cancer at the time of stroke, a cerebrovascular event may be the initial manifestation of a malignancy.
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Wilbers J, Sondag L, Mulder S, Siegerink B, van Dijk EJ. Cancer prevalence higher in stroke patients than in the general population: the Dutch String-of-Pearls Institute (PSI) Stroke study. Eur J Neurol 2019; 27:85-91. [PMID: 31299123 PMCID: PMC6916304 DOI: 10.1111/ene.14037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 07/08/2019] [Indexed: 01/14/2023]
Abstract
Background and purpose The aim of this study was to assess the prevalence of cancer and its characteristics in patients with ischemic stroke and to compare this with cancer prevalence in the general population. Methods This was a multicenter cohort study with 2736 patients presenting with ischemic stroke or transient ischemic attack. The prevalence of cancer was assessed by interview and verified by reviewing all medical records. In stroke patients with a history of cancer, we studied the subtype of cancer and its treatment characteristics. We used the national database of The Netherlands Cancer Registry to calculate population‐based age and sex cancer standardized prevalence ratios (SPRs) for patients with ischemic stroke. Results Cancer prevalence in ischemic stroke patients was 12%, corresponding to an SPR of 1.2 [95% confidence interval (CI), 1.0–1.3]. Increased SPRs were observed for cancer of the central nervous system (SPR, 18.2; 95% CI, 9.0–27.4), head and neck (SPR, 3.4; 95% CI, 2.3–4.6), lower respiratory tract (SPR, 2.4; 95% CI, 1.5–3.3) and urinary tract (SPR, 2.1; 95% CI, 1.4–2.9), but not for other cancer types. Cardiovascular risk factors, stroke etiology, treatment and outcome were not different between patients with or without a history of cancer. Conclusions In stroke patients, the prevalence of cancer, most prominently cancer of the central nervous system, head and neck, lower respiratory and urinary tract, was higher than in the general population. Medical treatment for the prevention of stroke in cancer survivors deserves further study.
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Affiliation(s)
- J Wilbers
- Center of Expertise for Cancer Survivorship, Radboud University Medical Center, Nijmegen, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Center for Neuroscience, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L Sondag
- Donders Institute for Brain, Cognition and Behaviour, Center for Neuroscience, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S Mulder
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - B Siegerink
- Department of Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Center for Stroke Research Berlin, Charite Universitätsmedizin Berlin, Berlin, Germany
| | - E J van Dijk
- Donders Institute for Brain, Cognition and Behaviour, Center for Neuroscience, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
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Wang F, Hu XY, Cui ZM, Fang XM, Dai Z, Wang T, Guo DL. Clinical and Imaging Characteristics of Malignant Tumor Concurrent with Stroke. Cancer Biother Radiopharm 2019; 34:504-510. [PMID: 31295003 DOI: 10.1089/cbr.2019.2853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objectives: The present study aimed to retrospectively compare the clinical and imaging characteristics and laboratory data of patients with malignant tumor concurrent with acute ischemic stroke (IS) and patients with cerebral infarction only, and to analyze the potential related risk factors. Method: A total of 126 patients with acute cerebral infarction concurrent with malignant tumor were collected and assigned to the malignant tumor group. In addition, 120 patients hospitalized for routine acute IS during the same period were randomly selected as the control group. Demographic data and common risk factors of cerebrovascular disease, laboratory data, and imaging characteristics in these two groups were compared. Results: In the malignant tumor group, the age of onset was relatively low, and the National Institutes of Health Stroke Scale score, 90 d recurrence rate, and fatality rate were higher than for those in the control group (p < 0.05). However, most patients had no traditional risk factors of stroke. Biochemical results revealed that the peripheral hemoglobin of patients with malignant tumor and cerebral infarction was lower than for those in the control group (p < 0.05). Furthermore, the levels of D-dimer, fibrinogen, tumor markers CA125, CA199, and carcinoembryonic antigen were significantly elevated, and the difference was statistically significant (p < 0.05). Magnetic resonance imaging results revealed that multiple intracranial infarcts were more common in patients in the malignant tumor group, and the difference was statistically significant compared with patients with cerebral infarction only (p < 0.05). Conclusion: Patients with cancer and IS had fewer traditional stroke risk factors but more anemia as well as higher D-dimer level, tumor marker rate, short-term mortality, and stroke recurrence rate. Furthermore, lower age of onset and other characteristics, including multiple intracranial infarcts, can be regarded as important characteristics of such patients.
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Affiliation(s)
- Feng Wang
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Xiao-Yun Hu
- Department of Radiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Zhi-Ming Cui
- Department of Radiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Xiang-Ming Fang
- Department of Radiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Zheng Dai
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Tao Wang
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Dao-Liu Guo
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
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Xian Z, Chen Y, Chen L, Lu Q, Huang G, Qin Q, Zeng J, Liang Z. A clinical research on the potential pathogenesis of somatic cancer related cerebral venous sinus thrombosis. Medicine (Baltimore) 2019; 98:e15134. [PMID: 31083150 PMCID: PMC6531122 DOI: 10.1097/md.0000000000015134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
To investigate the pathogenesis of somatic solid cancer-related cerebral venous sinus thrombosis (CVST).A total of 174 patients with CVST were recruited from the hospital between January 2006 and December 2017 and divided into two groups: (1) somatic cancer-related CVST group, defined as active somatic solid cancer patients with acute CVST; (2) cancer group (CG), defined as active somatic solid cancer patients without CVST. The cancer group patients were age and gender-matched somatic cancer-related CVST group patients. In addition, the types and amount distribution of cancer in cancer group were also matched with somatic cancer-related CVST group patients.Compared to cancer group patients, somatic cancer-related CVST group patients had more intracranial metastasis, a higher platelet count, higher plasma D-dimer, carcinoembryonic antigen (CEA) and cancer antigen (CA) 125 levels, a greater platelet to lymphocyte ratio (PLR), and a greater platelet to neutrophil ratio (PNR). The risk for CVST in somatic cancer-related CVST group patients increased independently by 0.7% (odds ratio [OR] 1.007; 95% confidence interval [CI] 1.000, 1.015; P = .047) with a 1 ng/ml increase in D-dimer levels, by 4.6% (OR 1.046; 95% CI 1.011, 1.083; P = .010) with a 1 U/ml increase in CEA, by 2.7% (OR 1.027; 95% CI 1.003, 1.051; P = .025) with a 1 U/ml increase in CA125, and by 10.6% (OR 1.106; 95% CI 1.002, 1.220; P = .045) with a 1 unit increase in PNR.It was suggested that together impacts of elevated plasma D-dimer, CA125, CEA levels, and a greater PNR may lead to hypercoagulability and to trigger the development of cancer-related CVST.
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Affiliation(s)
- Ziqiang Xian
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, 530021, Guangxi
| | - Yicong Chen
- Department of Neurology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, Guangdong, P.R. China
| | - Li Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, 530021, Guangxi
| | - Qiuhong Lu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, 530021, Guangxi
| | - Gelun Huang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, 530021, Guangxi
| | - Qixiong Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, 530021, Guangxi
| | - Jinsheng Zeng
- Department of Neurology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, Guangdong, P.R. China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-cerebrovascular Diseases, Nanning, 530021, Guangxi
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Qin K, Chen Y, Long H, Chen J, Wang D, Chen L, Liang Z. The biomarkers and potential pathogenesis of lung cancer related cerebral hemorrhage. Medicine (Baltimore) 2019; 98:e15693. [PMID: 31096511 PMCID: PMC6531149 DOI: 10.1097/md.0000000000015693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Cerebral hemorrhage is one of the common complications in patients with lung cancer (LC). Although cancer related cerebral hemorrhage was aware, the pathogenesis and biomarkers of lung cancer related cerebral hemorrhage (LCRCH) remained not well known. The aim of this study was to investigate the pathogenesis and plasma biomarkers of LCRCH.A retrospective review was conducted on acute cerebral hemorrhage patients with active LC who was admitted to the hospital between January 2007 and December 2017. A total of 56 patients with LCRCH (active LC patients with acute cerebral hemorrhage but without conventional vascular risks) was recruited. Meanwhile, 112 patients with active LC alone and gender, age, and subtype of cancer cell matched were recruited as control group.In LCRCH patients, most of the hemorrhagic lesions were located in lobes. And most of them with adenocarcinoma were in medium to terminal stage with poor prognosis short-term. Moreover, LCRCH patients had a lengthened prothrombin time (PT), elevated plasma carcinoembryonic antigen (CEA), cancer antigen 125 (CA125) and cancer antigen 199 (CA199) levels and decreased platelet (PLT) level than did the patients with LC. Multivariate logistic regression analysis showed that lengthened PT, elevated plasm CEA, and CA199 levels were independent risk factors for LCRCH.It was suggested that lengthened PT, elevated plasm CEA and CA199 levels associated with the pathogenesis of LCRCH, and that the Index derived from independent risks should be serve as a specific biomarker of LCRCH.
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Affiliation(s)
- Kemin Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning City, Guangxi
| | - Yicong Chen
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou City, Guangdong
| | - Haiyin Long
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning City, Guangxi
| | - Jiyun Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning City, Guangxi
| | - Dacheng Wang
- Department of Neurology, The Ninth Affiliated Hospital of Guangxi Medical University, Beihai City, Guangxi, PR China
| | - Li Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning City, Guangxi
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning City, Guangxi
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Wang JY, Zhang GJ, Zhuo SX, Wang K, Hu XP, Zhang H, Qu LD. D-dimer >2.785 μg/ml and multiple infarcts ≥3 vascular territories are two characteristics of identifying cancer-associated ischemic stroke patients. Neurol Res 2018; 40:948-954. [PMID: 30317943 DOI: 10.1080/01616412.2018.1504179] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The patterns and mechanisms underlying stroke in cancer patients differ from those of the conventional etiology. In this study, we further investigated the characteristics distinguishing cancer-associated ischemic stroke (CAIS) and the relationship of D-dimer value with CAIS. METHODS Sixty-one acute ischemic stroke patients with cancer (cancer group) and 76 stroke patients without cancer (control group) were recruited. Cerebrovascular distribution was divided into 3 circulations and 23 vascular territories, and acute multiple brain infarcts (AMBIs) were defined as discrete MRI diffusion-weighted imaging (DWI) lesions in >1 vascular territory. RESULTS Cancer patients had higher average D-dimer and fibrinogen degradation product values, and fewer stroke risk factors. The numbers of infarct-affected vascular territories, AMBIs, and AMBIs in multiple circulations were significantly higher in the cancer group. Receiver operating characteristic analysis showed that the cutoff value of D-dimer was 2.785 μg/ml; and above features were particularly evident in cancer patients whose D-dimer values were >2.785 μg/ml, while those with D-dimer values ≤2.785 μg/ml were similar to controls. CONCLUSIONS D-dimer >2.785 μg/ml may be an effective cutoff value and a sensitive index for identifying CAIS patients. AMBIs in ≥3 vascular territories and AMBIs in both the anterior and posterior circulations are two imaging characteristics of CAIS.
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Affiliation(s)
- Jing-Ye Wang
- a Department of Neurology , First Affiliated Hospital of Anhui Medical University , Hefei , China
| | - Gao-Jia Zhang
- a Department of Neurology , First Affiliated Hospital of Anhui Medical University , Hefei , China.,b Department of Neurology , Nanjing Lishui People,s Hospital , Nanjing , China
| | - Sheng-Xia Zhuo
- c Department of Oncology , First Affiliated Hospital of Anhui Medical University , Hefei , China
| | - Kai Wang
- a Department of Neurology , First Affiliated Hospital of Anhui Medical University , Hefei , China
| | - Xiao-Peng Hu
- d Department of Radiology , First Affiliated Hospital of Anhui Medical University , Hefei , China
| | - Hui Zhang
- d Department of Radiology , First Affiliated Hospital of Anhui Medical University , Hefei , China
| | - Lin-di Qu
- a Department of Neurology , First Affiliated Hospital of Anhui Medical University , Hefei , China
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29
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Navi BB, Iadecola C. Ischemic stroke in cancer patients: A review of an underappreciated pathology. Ann Neurol 2018; 83:873-883. [PMID: 29633334 PMCID: PMC6021225 DOI: 10.1002/ana.25227] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 04/02/2018] [Accepted: 04/02/2018] [Indexed: 02/06/2023]
Abstract
Currently 1 in 10 patients with ischemic stroke have comorbid cancer, and this frequency is expected to increase with continued advances in cancer therapeutics prolonging median survival. Well known for its association with venous thrombosis, cancer has recently emerged as a significant risk factor for arterial thromboembolism, including stroke; however, the underlying mechanisms are uncertain. In addition, the optimal strategies to prevent and acutely treat stroke in cancer patients are yet to be established. This review summarizes the current evidence on ischemic stroke risk, biomarkers, pathophysiology, treatments, and prognosis in cancer patients, emphasizing knowledge gaps and the potential strategies to address them. Ann Neurol 2018;83:873-883.
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Affiliation(s)
- Babak B Navi
- Department of Neurology
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Costantino Iadecola
- Department of Neurology
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
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30
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Long H, Qin K, Chen J, Chen Y, Chen L, Zeng J, Liang Z. Biomarkers of gastric cancer-related ischemic stroke and its underlying pathogenesis. Medicine (Baltimore) 2018; 97:e0493. [PMID: 29703010 PMCID: PMC5944483 DOI: 10.1097/md.0000000000010493] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
This study aimed to investigate the biomarkers and underlying pathogenesis of ischemic stroke in patients with gastric cancer (GC).Patients with active gastric cancer who had experienced acute ischemic stroke without conventional vascular risk factors (gastric cancer-related stroke [GCS] group) and visited The First Affiliated Hospital of Guangxi Medical University and First Affiliated Hospital of Sun Yat-sen University from January 2003 to December 2016 were retrospectively enrolled. The patients' clinical features and laboratory findings were compared with those of age-, sex-, and disease progression-matched patients with GC without ischemic stroke (GC group) who had been admitted to the same hospital during the same period (GCS:GC ratio = 1:2).Among the 9166 patients diagnosed with GC, 70 had experienced a cerebral infarction and were enrolled in this study. Among them, 53 (75.71%) harbored multiple lesions in multiple vascular territories. Notably, patients in the GCS group exhibited significant increases in the D-dimer and cancer antigen 125 (CA125) levels and platelet-to-neutrophil ratio (PNR), compared to their counterparts in the GC group. A multiple logistic regression analysis identified all 3 factors as independent risk factors for cerebral infarction in patients with GC (D-dimer, odds ratio [OR] = 1.006 per 1 ng/mL increase, 95% confidence interval [CI], 1.004-1.009, P = .000; CA125, OR = 1.016 per 1 U/mL increase, 95% CI, 1.005-1.027, P = .005; PNR, OR = 1.025 per 1 point increase, 95% CI: 1.003-1.048, P = .023).Elevated plasma D-dimer and CA125 levels and an increased PNR might affect the occurrence of GC-related ischemic stroke and could therefore serve as potential biomarkers.
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Affiliation(s)
- Haiyin Long
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning City, Guangxi Province
| | - Kemin Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning City, Guangxi Province
| | - Jiyun Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning City, Guangxi Province
| | - Yicong Chen
- Department of Neurology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Li Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning City, Guangxi Province
| | - Jinsheng Zeng
- Department of Neurology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning City, Guangxi Province
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Sorgun MH, Kuzu M, Ozer IS, Yilmaz V, Ulukan C, Cotur Levent H, Tezcan S, Rzayev S, Rawandi A, Bakırarar B, Isikay CT. Risk Factors, Biomarkers, Etiology, Outcome and Prognosis of Ischemic Stroke in Cancer Patients. Asian Pac J Cancer Prev 2018; 19:649-653. [PMID: 29580034 PMCID: PMC5980836 DOI: 10.22034/apjcp.2018.19.3.649] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2017] [Indexed: 12/15/2022] Open
Abstract
Introduction: Cerebrovascular disease is the second most common complication in individuals with tumours. The aim of this study was to investigate risk factors, biomarkers, etiology and prognosis of ischemic stroke in cancer patients (ISCPs). Methods: The medical records of 619 consecutive patients who were admitted with acute ischemic stroke from January 2012 to November 2014 were retrospectively evaluated. The patients were divided into two groups (group 1, patients with an active cancer prior to the onset of ischemic stroke; group 2, patients without an active cancer history). The demographic data, risk factors, NIHSS scores, thrombocyte count, D-dimer, fibrinogen and C reactive protein (CRP) level at admission, modified Rankin Scale (mRS) scores in the follow-up period and location of lesions on DWI were recorded. The Mann-Whitney U test, chi-squared test and logistic regression was used for analyzing data, p<0.05 being considered statistically significant. Results: A total of 46 (7.4%) ISCPs were included. Hyperlipidemia was significantly lower in the ISCP group (p=0.001). Elevated thrombocyte counts, D-dimer, fibrinogen and CRP levels at admission, acute multiple ischemic lesions, other causes, mortality in hospital and worse outcome were significantly related to ISCP (p<0.05). On logistic regression analysis, follow up mRS>3, acute multiple ischemic lesions located in more than one vascular territory (AMIMCT) and other causes were significantly associated with ISCP (p<0.001). Conclusion: In our study, other causes, AMIMCT and mRS>3 were more common in the ISCP group. We consider that CCS could be more suitable for detecting other causes than TOAST. Biomarkers could be important in the ISCP group.
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Affiliation(s)
- Mine Hayriye Sorgun
- Ankara University School of Medicine, İbni Sina Hospital, Department of Neurology, Samanpazarı, Ankara Turkey.
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Temporal changes in the neutrophil to lymphocyte ratio and the neurological progression in cryptogenic stroke with active cancer. PLoS One 2018; 13:e0194286. [PMID: 29547637 PMCID: PMC5856344 DOI: 10.1371/journal.pone.0194286] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 02/28/2018] [Indexed: 12/11/2022] Open
Abstract
Background Ischemic stroke patients with active cancer frequently experience early neurological deterioration (END); however, the predictors of END are not well studied. The neutrophil to lymphocyte ratio (NLR) has recently been described as a predictor of poor outcomes in cancer and stroke. However, its role in cancer-related stroke has not been addressed. Aim We aimed to evaluate the association between the NLR and END in cancer-related stroke patients. Methods We included 85 cryptogenic stroke patients with active cancer. END was defined as an increase ≥ 4 on the total National Institutes of Health Stroke Scale (NIHSS) score within 72 hours of admission. The NLR was calculated as the ratio of the absolute neutrophil count to the absolute lymphocyte count. We obtained the NLR during the following three periods: at admission, 1–3 days after admission (D 1–3 NLR) and 4–7 days after admission (D 4–7 NLR). Results END occurred in 15 (18%) of the 85 patients. END was significantly associated with the initial NIHSS score, infarction volume, and the D 1–3 NLR. In multivariate analysis, a higher D 1–3 NLR, measured before END events, remained an independent predictor of END [adjusted odds ratio = 2.78, 95% confidence interval = 1.09–7.08, P = 0.032]. In terms of temporal changes in the NLR, the END group showed a tendency toward temporal increase in the NLR at D 1–3 (P = 0.061) with subsequent decrements in the D 4–7 NLR (P = 0.088), while the non-END group showed no significant changes in the NLR between periods. Conclusions This study demonstrated that a higher NLR could predict END events in cryptogenic stroke patients with active cancer. However, the results should be confirmed in further large prospective studies.
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Parikh NS, Burch JE, Kamel H, DeAngelis LM, Navi BB. Recurrent Thromboembolic Events after Ischemic Stroke in Patients with Primary Brain Tumors. J Stroke Cerebrovasc Dis 2017. [PMID: 28647417 DOI: 10.1016/j.jstrokecerebrovasdis.2017.05.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Stroke mechanisms and the risk of recurrent thromboembolism are incompletely understood in patients with primary brain tumors. We sought to better delineate these important clinical features. METHODS We performed a retrospective cohort study of adults with primary brain tumors diagnosed with magnetic resonance imaging-confirmed acute ischemic stroke at the Memorial Sloan Kettering Cancer Center from 2005 to 2015. Study neurologists collected data on patients' cancer history, stroke risk factors, treatments, and outcomes. Stroke mechanisms were adjudicated by consensus. The primary outcome was recurrent thromboembolism (arterial or venous) and the secondary outcome was recurrent ischemic stroke. Kaplan-Meier statistics were used to calculate cumulative outcome rates, and Cox hazards analysis was used to evaluate the association between potential risk factors and outcomes. RESULTS We identified 83 patients with primary brain tumors and symptomatic acute ischemic stroke. Median survival after index stroke was 2.2 years (interquartile range, .5-7.0). Tumors were mostly gliomas (72%) and meningiomas (13%). Most strokes were from unconventional mechanisms, particularly radiation vasculopathy (36%) and surgical manipulation (18%). Small- or large-vessel disease or cardioembolism caused 13% of strokes, whereas 29% were cryptogenic. Cumulative recurrent thromboembolism rates were 11% at 30 days, 17% at 180 days, and 27% at 365 days, whereas cumulative recurrent stroke rates were 5% at 30 days, 11% at 180 days, and 13% at 365 days. We found no significant predictors of outcomes. CONCLUSION Patients with primary brain tumors generally develop strokes from rare mechanisms, and their risk of recurrent thromboembolism, including stroke, is high.
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Affiliation(s)
- Neal S Parikh
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Jaclyn E Burch
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, New York; Clinical and Translational Neuroscience Unit, Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Lisa M DeAngelis
- Department of Neurology, Weill Cornell Medicine, New York, New York; Clinical and Translational Neuroscience Unit, Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York; Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak B Navi
- Department of Neurology, Weill Cornell Medicine, New York, New York; Clinical and Translational Neuroscience Unit, Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York; Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York.
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Jiang H, Qin C, Cheng D, Lu Q, Huang G, Wang D, Yang H, Liang Z. Potential Pathogenesis and Biomarkers of Kidney Cancer-Related Stroke. Med Sci Monit 2017; 23:2292-2298. [PMID: 28505148 PMCID: PMC5441415 DOI: 10.12659/msm.904710] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Stroke risk and stroke recurrence are increased in cancer patients, but the pathogenesis and biomarkers of kidney cancer-related stroke (KCS) are generally unclear. The aim of the present research was to investigate the pathogenesis and plasma biomarkers of kidney cancer-related stroke. MATERIAL AND METHODS A retrospective review was conducted on acute stroke patients with kidney cancer (KC) who were admitted to the hospital between January 2006 and December 2015. A total of 106 patients with KCS (active KC patients with acute stroke but without conventional vascular risks) were identified. In addition, 106 age- and sex-matched patients with KC alone were recruited. RESULTS KCS patients had higher plasma D-dimer, cancer antigen (CA) 125, and CEA levels and greater proteinuria levels than did KC patients. Multiple logistic regression analysis showed that the risk of stroke in patients with KC increased independently by 0.8% (odds ratio [OR] 1.008; 95% confidence interval [CI] 1.002, 1.013; p=0.004) with a 1 ng/mL increase in D-dimer levels, by 1.2% (OR 1.012; 95% CI 1.007, 1.018; p=0.000) with a 1 U/mL increase in CA125, by 2.5% (OR 1.025; 95% CI 1.012, 1.038; p=0.000) with a 1 U/mL increase in CEA by 1.4% (OR 1.014; 95% CI 1.005, 1.024; p=0.004) with a 1 mg increase in urine protein in 24 hours. CONCLUSIONS Elevated plasma D-dimer, CA125 and CEA levels, and increased urine protein levels might lead to hypercoagulability and then KCS; however, they may also be biomarkers of KCS.
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Affiliation(s)
- Haihong Jiang
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Chao Qin
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Daobin Cheng
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Qiuhong Lu
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Gelun Huang
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Dacheng Wang
- Department of Neurology, Ninth Affiliated Hospital of Guangxi Medical University, Beihai, Guangxi, China (mainland)
| | - Hong Yang
- Department of Neurology, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China (mainland)
| | - Zhijian Liang
- Department of Neurology, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
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Xie X, Chen L, Zeng J, Qin C, Cheng D, Wei X, Liang Z. Clinical features and biological markers of lung cancer-associated stroke. J Int Med Res 2016; 44:1483-1491. [PMID: 28322105 PMCID: PMC5536770 DOI: 10.1177/0300060516666398] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective To identify the unique clinical features and biological markers of lung cancer-associated stroke. Methods We recruited 102 patients with lung cancer plus stroke, 102 with lung cancer, and 102 with stroke. Detailed information was analysed and compared among groups. Results The groups were age-matched. Patients with lung cancer plus stroke showed multiple lesions involving multiple cerebral artery territories on magnetic resonance imaging, compared with stroke-alone patients. These patients also had a poorer modified Rankin Scale score at 30 days, and high mortality (18.6%). Patients with lung cancer plus stroke had a higher incidence of metastasis, and higher blood levels of D-dimer, CA125 and CA199 compared with patients with lung cancer alone. Multivariate logistic regression analysis showed that levels of D-dimer, CA125 and CA199 were independently related to lung cancer-associated stroke. Conclusion Elevated plasma D-dimer, CA125 and CA199 may be independent risk factors for and biomarkers of lung cancer-associated stroke.
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Affiliation(s)
- Xingrui Xie
- 1 Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Li Chen
- 1 Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jinsheng Zeng
- 2 Department of Neurology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chao Qin
- 1 Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Daobin Cheng
- 1 Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xinxian Wei
- 1 Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhijian Liang
- 1 Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Schwarzbach CJ, Fatar M, Eisele P, Ebert AD, Hennerici MG, Szabo K. DWI Lesion Patterns in Cancer-Related Stroke--Specifying the Phenotype. Cerebrovasc Dis Extra 2015; 5:139-45. [PMID: 26648971 PMCID: PMC4662270 DOI: 10.1159/000439549] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 08/14/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Due to the lack of specific diagnostic markers, the diagnosis of cancer-related stroke strongly depends on its phenotype. Distinct DWI lesion patterns with involvement of multiple vascular territories have been reported repeatedly in cancer-related stroke but have not been addressed in detail in a selected cohort of prospectively recruited cancer patients with emphasis on hypercoagulable conditions. PATIENTS AND METHODS Ischemic stroke patients with known malignant cancer activity, laboratory evidence of strong plasmatic hypercoagulation (D-dimer levels > 3 µg/ml) and without competing stroke etiologies according to the recently introduced ASCOD (A - atherosclerosis, S - small vessel disease, C - cardiac pathology, O - other cause, and D - dissection) classification of evidence-rated etiology of stroke subtypes were included in the analysis. Cerebral MRI on admission was reviewed with respect to ischemic lesion patterns. RESULTS Thirty-two patients met the inclusion criteria. The mean D-dimer levels were 15.39 µg/ml (± 10.84). Acute infarction in ≥ 2 vascular territories was present in 27/32 (84%) patients. (Micro-) embolic scattering of infarction was present in 25/32 (78%) patients. Evidence for previous, potentially oligosymptomatic infarction was found in 16 (50%) patients, demonstrated by the additional presence of subacute or chronic ischemic lesions. CONCLUSION When excluding competing embolic and nonembolic stroke etiologies, the pattern of scattered DWI lesions in multiple vascular supply territories strongly dominates the phenotype of cancer-related stroke. Additionally, evidence of recurrent infarction is frequent in this cohort of patients. This is not only important for the diagnosis of cancer-related stroke itself but may prove helpful for the identification of cancer-related stroke patients with unknown malignancy at the time of stroke manifestation and evaluation of strategies for secondary prevention.
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Comparison of Enoxaparin and Warfarin for Secondary Prevention of Cancer-Associated Stroke. JOURNAL OF ONCOLOGY 2015; 2015:502089. [PMID: 26064116 PMCID: PMC4439482 DOI: 10.1155/2015/502089] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 04/22/2015] [Indexed: 01/29/2023]
Abstract
Background. The aim of this study was to determine which anticoagulant is superior for secondary prevention of cancer-associated stroke, using changes in D-dimer levels as a biomarker for recurrent thromboembolic events. Methods. We conducted a retrospective, single center observational study including patients with cancer-associated stroke who were treated with either enoxaparin or warfarin. Blood samples for measuring the initial and follow-up D-dimer levels were collected at admission and a median of 8 days after admission, respectively. Multiple logistic regression analysis was conducted to evaluate the factors that influenced D-dimer levels after treatment. Results. Although the initial D-dimer levels did not differ between the two groups, the follow-up levels were dramatically decreased in patients treated with enoxaparin, while they did not change with use of warfarin (3.88 μg/mL versus 17.42 μg/mL, p = 0.026). On multiple logistic regression analysis, use of warfarin (OR 12.95; p = 0.001) and the presence of systemic metastasis (OR 18.73; p = 0.017) were independently associated with elevated D-dimer levels (≥10 μg/mL) after treatment. Conclusion. In cancer-associated stroke patients, treatment with enoxaparin may be more effective than treatment with warfarin for lowering the D-dimer levels. Future prospective studies are warranted to show that enoxaparin is better than warfarin for secondary prevention in cancer-associated stroke.
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Merkler AE, Navi BB, Singer S, Cheng NT, Stone JB, Kamel H, Iadecola C, Elkind MSV, DeAngelis LM. Diagnostic yield of echocardiography in cancer patients with ischemic stroke. J Neurooncol 2015; 123:115-21. [PMID: 25851114 DOI: 10.1007/s11060-015-1768-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 04/02/2015] [Indexed: 12/21/2022]
Abstract
The yield of echocardiography in cancer patients with acute ischemic stroke is unknown. We identified adult patients with active systemic cancer diagnosed with acute ischemic stroke at a tertiary-care cancer center from 2005 through 2009 who underwent transthoracic (TTE) or transesophageal echocardiography (TEE). Two neurologists independently reviewed all clinical data, including TTE and TEE reports, and adjudicated whether echocardiographic studies revealed a definite or possible source of stroke according to pre-defined criteria. Patients were classified as having suspected cardioembolic strokes if imaging showed embolic-appearing infarcts in more than one vascular territory. Among 220 patients with cancer and ischemic stroke who underwent echocardiography, 216 (98%) had TTE and 37 (17%) had TEE. TTE revealed a definite source in 15 (7%, 95% CI 4-10%) patients and a possible source in 42 (19%, 95% CI 14-25%), while TEE revealed a definite source in 10 (27%, 95% CI 12-42%) patients and a possible source in 14 (38%, 95% CI 21-54%). In 92 patients with suspected cardioembolic strokes who underwent TTE, 6 (7%, 95% CI 1-12%) had a definite source, including 4 with marantic endocarditis, and 20 (22%, 95% CI 13-30%) had a possible source. Twenty-one of these patients also underwent TEE, which demonstrated a definite or possible source in 16 (76%, 95% CI 56-96%) patients, including marantic endocarditis in 4 (19%). The yield of TTE for detecting marantic endocarditis and other cardiac sources of stroke in cancer patients is low, but TEE may provide a higher yield in targeted patients.
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Affiliation(s)
- Alexander E Merkler
- Department of Neurology, Weill Cornell Medical College, 525 East 68th Street, Room F610, New York, NY, 10065, USA
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Kim K, Lee JH. Risk factors and biomarkers of ischemic stroke in cancer patients. J Stroke 2014; 16:91-6. [PMID: 24949315 PMCID: PMC4060273 DOI: 10.5853/jos.2014.16.2.91] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/01/2013] [Accepted: 11/01/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND PURPOSE Stroke is common among cancer patients. However, risk factors and biomarkers of stroke in cancer patients are not well established. This study aimed to investigate risk factors and biomarkers as well as etiology of ischemic stroke in cancer patients. METHODS A retrospective review was conducted in cancer patients with ischemic stroke who were admitted to a general hospital in Busan, Korea, between January 2003 and December 2012. The risk factors and biomarkers for stroke and stroke subtypes in cancer patients were compared with age- and sex-matched noncancer patients with ischemic stroke who were admitted to the same hospital during the same period. RESULTS One hundred fifty-six cancer patients with ischemic stroke were identified. Cancer patients with ischemic stroke were found to have a significantly lower proportion of hypertension, atrial fibrillation, hyperlipidemia, and ischemic heart disease than noncancer patients with ischemic stroke. However, stroke biomarkers, such as erythrocyte sedimentation rate and high-sensitivity C-reactive protein, fibrinogen, pro-brain natriuretic peptide, and D-dimer levels, were significantly increased in cancer patients with ischemic stroke than in noncancer patients. Large-artery atherosclerosis and stroke of undetermined cause were more common in cancer patients with ischemic stroke than in noncancer patients with ischemic stroke. CONCLUSIONS Cancer patients with ischemic stroke showed different risk factors, stroke biomarkers, and stroke etiology compared with noncancer patients with ischemic stroke.
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Affiliation(s)
- Kwangsoo Kim
- Department of Neurology, Kosin University College of Medicine, Busan, Korea
| | - Ji-Hun Lee
- Department of Neurology, Kosin University College of Medicine, Busan, Korea
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Lau KK, Wong YK, Teo KC, Chang RSK, Hon SFK, Chan KH, Cheung RTF, Li LSW, Tse HF, Ho SL, Siu CW. Stroke patients with a past history of cancer are at increased risk of recurrent stroke and cardiovascular mortality. PLoS One 2014; 9:e88283. [PMID: 24523883 PMCID: PMC3921146 DOI: 10.1371/journal.pone.0088283] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 01/07/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND PURPOSE Cancer patients are at increased risk of cardiovascular and cerebrovascular events. It is unclear whether cancer confers any additional risk for recurrent stroke or cardiovascular mortality after stroke. METHODS This was a single center, observational study of 1,105 consecutive Chinese ischemic stroke patients recruited from a large stroke rehabilitation unit based in Hong Kong. We sought to determine whether patients with cancer are at higher risk of recurrent stroke and cardiovascular mortality. RESULTS Amongst 1,105 patients, 58 patients (5.2%) had cancer, of whom 74% were in remission. After a mean follow-up of 76 ± 18 months, 241 patients developed a recurrent stroke: 22 in patients with cancer (38%, annual incidence 13.94%/year), substantially more than those without cancer (21%, 4.65%/year) (p<0.01). In a Cox regression model, cancer, age and atrial fibrillation were the 3 independent predictors of recurrent stroke with a hazard ratio (HR) of 2.42 (95% confidence interval (CI): 1.54-3.80), 1.01 (1.00-1.03) and 1.35 (1.01-1.82) respectively. Likewise, patients with cancer had a higher cardiovascular mortality compared with those without cancer (4.30%/year vs. 2.35%/year, p = 0.08). In Cox regression analysis, cancer (HR: 2.08, 95% CI: 1.08-4.02), age (HR: 1.04, 95% CI 1.02-1.06), heart failure (HR: 3.06, 95% CI 1.72-5.47) and significant carotid atherosclerosis (HR: 1.55, 95% CI 1.02-2.36) were independent predictors for cardiovascular mortality. CONCLUSIONS Stroke patients with a past history of cancer are at increased risk of recurrent stroke and cardiovascular mortality.
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Affiliation(s)
- Kui-Kai Lau
- Division of Neurology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
- Research Center of Heart, Brain, Hormone and Healthy Aging, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yuen-Kwun Wong
- Division of Neurology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Kay-Cheong Teo
- Division of Neurology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Richard Shek-Kwan Chang
- Division of Neurology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Sonny Fong-Kwong Hon
- Division of Neurology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Koon-Ho Chan
- Division of Neurology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
- Research Center of Heart, Brain, Hormone and Healthy Aging, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Raymond Tak-Fai Cheung
- Division of Neurology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
- Research Center of Heart, Brain, Hormone and Healthy Aging, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Leonard Sheung-Wai Li
- Division of Rehabilitation Medicine, Department of Medicine, Tung Wah Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Hung-Fat Tse
- Research Center of Heart, Brain, Hormone and Healthy Aging, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Shu-Leong Ho
- Division of Neurology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
- Research Center of Heart, Brain, Hormone and Healthy Aging, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- * E-mail: (CWS); (SLH)
| | - Chung-Wah Siu
- Research Center of Heart, Brain, Hormone and Healthy Aging, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
- * E-mail: (CWS); (SLH)
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