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Tang KJY, Saffari SE, Narasimhalu K, Queck KK, De Silva DA. Non-Hypertensives and Those with Normal Cholesterol Are More Likely to Have Concomitant Cancer amongst Patients with Ischemic Stroke: A Retrospective Cross-Sectional Registry-Based Study. Cerebrovasc Dis Extra 2023; 13:75-82. [PMID: 37778336 PMCID: PMC10616664 DOI: 10.1159/000534267] [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: 06/20/2023] [Accepted: 09/15/2023] [Indexed: 10/03/2023] Open
Abstract
INTRODUCTION Patients with cancer are known to have an increased risk of ischemic stroke (IS) around the time of their diagnosis. However, there is a paucity of data in Asian populations, and as such, we aimed to determine cancer incidence rates and patterns in Asian IS patients as well as investigate the differences in vascular risk profile of IS patients with and without concomitant cancer. METHODS We conducted a retrospective cross-sectional study using data from the Singapore Stroke and Cancer registries. We defined cases as patients with IS and a cancer diagnosis 2 years before or after the index IS. Cancer incidence was determined using the same direct age-standardization method performed for the Singapore general population in the 2015 Singapore cancer report. Multivariable logistic regression was used to analyze differences in vascular risk factors. RESULTS Among 21,068 IS patients (mean age, 67.9 ± 13.3 years), 6.3% (1,330) were found to have concomitant cancer; 4.4% (935) had prior cancer while 1.8% (395) had cancer diagnoses within 2 years following IS. The cancer incidence among IS patients was 3,393 (95% confidence interval [CI], 1,937-4,849) per 100,000 person-years compared to 219-231 per 100,000 person-years in the general population. Older age (odds ratio [OR], 1.02 [95% CI, 1.01-1.02] per year), males (OR, 1.25 [95% CI, 1.11-1.41), Chinese ethnicity (OR, 1.61 [95% CI, 1.37-1.89]) and a lower prevalence of hypertension (OR, 0.84 [95% CI, 0.73-0.97)]), and hyperlipidemia (OR, 0.53 [95% CI, 0.45-0.62]) were independently associated with cancer-related IS. CONCLUSIONS The age-standardized cancer incidence was 15 times higher in IS patients than the general population. IS patients with concomitant cancer were older and had a lower prevalence of vascular risk factors.
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Affiliation(s)
| | - Seyed Ehsan Saffari
- Duke-NUS Medical School, Centre of Quantitative Medicine, Singapore, Singapore
| | - Kaavya Narasimhalu
- Duke-NUS Medical School, Singapore, Singapore
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus), Singapore, Singapore
| | - Kian Kheng Queck
- KK Queck Neurology Centre, Mount Alvernia Hospital, Singapore, Singapore
| | - Deidre Anne De Silva
- Duke-NUS Medical School, Singapore, Singapore
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus), Singapore, Singapore
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Mosconi MG, Capponi A, Paciaroni M. Systemic thrombolysis in patients with acute stroke and active cancer: a systematic review and meta-analysis. Intern Emerg Med 2023; 18:1843-1850. [PMID: 37337013 DOI: 10.1007/s11739-023-03312-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 05/11/2023] [Indexed: 06/21/2023]
Abstract
Cancer patients frequently have concomitant cerebrovascular diseases, which significantly worsen their prognosis. Prospective studies validating intravenous thrombolysis (IVT) safety profile in patients with acute ischemic stroke and active cancer are still lacking. Therefore, we aimed to evaluate IVT's efficacy and safety profile in acute ischemic stroke patients with comorbid active cancer. We included in a meta-analysis all relevant published studies, including patients with acute ischemic stroke with or without active cancer and receiving IVT, according to recommendations for IVT treatment for acute ischemic stroke. The primary outcomes were: any intracerebral hemorrhage, all-cause mortality, and good functional outcome reported as modified Rankin Scale (mRS) ≤ 2 at the end of the scheduled follow-up period. We included 11 studies in the meta-analysis. IVT was not associated with a significant increase in the incidence of intracerebral hemorrhage (OR 1.35; 95% CI 0.85-2.14; I2 76%), nor with a significant increase in death for any cause (OR 1.26; 95% CI 0.91-1.75; I2 71%); furthermore, IVT did not influence mRS between cancer and non-active cancer stroke patients (OR 0.72; 95% CI 0.35-1.49; I2 59%). IVT seems safe and effective in patients with ischemic stroke and concomitant cancer. Due to the low overall quality of the evidence, high-quality randomized controlled trials with adequate sample sizes are needed.
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Affiliation(s)
- Maria Giulia Mosconi
- Internal and Vascular and Emergency Medicine-Stroke Unit, Università degli Studi di Perugia/Azienda Ospedaliera Santa Maria della Misericordia, 06129, Perugia, Italy.
| | - Andrea Capponi
- Emergency Department, University of Florence, Florence, Italy
| | - Maurizio Paciaroni
- Internal and Vascular and Emergency Medicine-Stroke Unit, Università degli Studi di Perugia/Azienda Ospedaliera Santa Maria della Misericordia, 06129, Perugia, Italy
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Vaz CG, Rodrigues J, Pereira D, Matos I, Oliveira C, Bento MJ, Magalhães R, Correia M, Maia LF. The crosstalk between Stroke and Cancer: Incidence of cancer after a first-ever cerebrovascular event in a population-based study. Eur Stroke J 2023; 8:792-801. [PMID: 37317526 PMCID: PMC10472965 DOI: 10.1177/23969873231181628] [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: 03/17/2023] [Accepted: 05/26/2023] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVES To determine the cancer incidence after the first-ever cerebrovascular event (CVE) and compare it to the cancer incidence in the population from the same region. METHODS We evaluated 1069 patients with a first-ever CVE (Ischaemic or haemorrhagic stroke and Transient Ischaemic Attack) from a prospective population registry of stroke and transient focal neurological attacks, diagnosed between 2009 and 2011. We conducted a structured search to identify cancer-related variables and case-fatality for a period of 8 years following CVE. Cancer incidence in CVE patients was compared to the North Region Cancer Registry (RORENO). RESULTS We found that 90/1069 (8.4%) CVE patients developed cancer after a first-ever CVE. Overall cancer annual incidence rate was higher after a CVE (820/100,000, 95%CI: 619-1020) than in general population (513/100,000, 95%CI: 508-518). In the 45-54 age group cancer incidence post-CVE was 3.2-fold (RR, 95%CI: 1.6-6.4) higher compared to the general population, decreasing gradually in older age-groups. Median time between CVE and cancer was 3.2 years (IQR = 1.4-5.2). Lower respiratory tract and colorectal were the most frequent cancer types. In univariable models, male sex (sHR = 1.78, 95%CI: 1.17-2.72, p = 0.007), tobacco use (sHR = 2.04, 95%CI: 1.31-3.18, p = 0.002) and peripheral artery disease (sHR = 2.37, 95%CI: 1.10-5.13, p = 0.028) were associated to higher cancer risk after CVE. After adjustment, tobacco use (sHR = 1.84, 95%CI: 1.08-3.14, p = 0.026) remained associated to a higher risk of cancer. CONCLUSIONS At the population level, patients presenting a first-ever CVE have higher cancer incidence, that is particularly prominent in younger age-groups. Higher cancer incidence, delayed cancer diagnosis and increased mortality post-CVE warrants further research on long-term cancer surveillance in first-ever CVE survivors.
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Affiliation(s)
- Catarina Guedes Vaz
- Serviço de Neurologia, Hospital Santo António – Centro Hospitalar Universitário de Santo António (HSA-CHUdSA), Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar – Universidade do Porto (ICBAS-UP), Porto, Portugal
| | - Jéssica Rodrigues
- Grupo de Epidemiologia do Cancro, Centro de Investigação do Instituto Português de Oncologia do Porto, Instituto Português de Oncologia do Porto, Porto, Portugal
| | - Diogo Pereira
- Serviço de Neurologia, Hospital Santo António – Centro Hospitalar Universitário de Santo António (HSA-CHUdSA), Porto, Portugal
| | - Ilda Matos
- Serviço de Neurologia, Unidade Local de Saúde do Nordeste – Mirandela, Mirandela, Portugal
| | - Carla Oliveira
- i3S – Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Ipatimup – Institute of Molecular Pathology and Immunology of the University of Porto, Porto, Portugal
| | - Maria José Bento
- Instituto de Ciências Biomédicas Abel Salazar – Universidade do Porto (ICBAS-UP), Porto, Portugal
- Grupo de Epidemiologia do Cancro, Centro de Investigação do Instituto Português de Oncologia do Porto, Instituto Português de Oncologia do Porto, Porto, Portugal
| | - Rui Magalhães
- Instituto de Ciências Biomédicas Abel Salazar – Universidade do Porto (ICBAS-UP), Porto, Portugal
| | - Manuel Correia
- Serviço de Neurologia, Hospital Santo António – Centro Hospitalar Universitário de Santo António (HSA-CHUdSA), Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar – Universidade do Porto (ICBAS-UP), Porto, Portugal
| | - Luis F Maia
- Serviço de Neurologia, Hospital Santo António – Centro Hospitalar Universitário de Santo António (HSA-CHUdSA), Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar – Universidade do Porto (ICBAS-UP), Porto, Portugal
- i3S – Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
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4
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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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5
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Blustein P, Werner S, Sham S, Febles A, Katz H, Villella J. Right middle cerebral artery stroke secondary to ovarian clear cell carcinoma in a 35-year-old: A case report. Case Rep Womens Health 2023; 37:e00485. [PMID: 36820401 PMCID: PMC9938153 DOI: 10.1016/j.crwh.2023.e00485] [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: 01/29/2023] [Revised: 02/04/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
Thromboembolic events (TEEs) can be classified into two types: venous TEEs (vTEEs), such as pulmonary embolism (PE) and deep vein thrombosis (DVT), and arterial TEEs (ATEs), such as acute myocardial infarction and cerebral infarction. Ovarian cancer has a high incidence of venous thromboembolism, with the clear cell subtype carrying the highest risk. However, the incidence of ATEs, especially cerebral infarction, in patients with ovarian carcinoma, of all subtypes, is much lower. This report is of a rare case of a 35-year-old Asian woman who presented with sudden onset of left hemiplegia and right gaze as the first presenting signs of an underlying ovarian malignancy. The patient had no pertinent medical history and no underlying cardiovascular risk factors. Final diagnosis was stage 2B clear cell carcinoma of the ovary without lymphovascular invasion arising from endometriosis. Patients who suffer from arterial thrombosis without known atherosclerotic risk factors should undergo further evaluations to rule out the possibility of cancer, particularly ovarian carcinoma.
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Affiliation(s)
- Pegah Blustein
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Blvd, Hempstead, NY 11549, United States,Corresponding author at: Department of Obstetrics and Gynecology Department of Gynecology Oncology, Lenox Hill Hospital, Northwell Health, 100 East 77th Street, NY 10075, USA.
| | - Sarah Werner
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology Lenox Hill Hospital, 100 E 77th St, New York, NY 10075, United States
| | - Sunder Sham
- Department of Pathology, Lenox Hill Hospital, 100 E 77th St, New York, NY 10075, United States
| | - Anthony Febles
- Department of Hematology / Oncology, Phelps Memorial Hospital Center, 701 N Broadway, Sleepy Hollow, NY 10591, United States
| | - Heather Katz
- Department of Radiology, Phelps Memorial Hospital Center, 701 N Broadway, Sleepy Hollow, NY 10591, United States
| | - Jeannine Villella
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology Lenox Hill Hospital, 100 E 77th St, New York, NY 10075, United States
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6
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Toda Y, Kano Y. Three-territory sign in Trousseau's syndrome. BMJ Case Rep 2022; 15:e253520. [PMID: 36368738 PMCID: PMC9660682 DOI: 10.1136/bcr-2022-253520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yuki Toda
- Department of Internal Medicine, Mito Kyodo General Hospital, Mito, Ibaraki, Japan
| | - Yasuhiro Kano
- Department of Internal Medicine, Mito Kyodo General Hospital, Mito, Ibaraki, Japan
- Department of General Internal Medicine, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
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7
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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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8
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Babici D, Johansen PM, Rodriguez-Hernandez A, Sommerville S, Snelling B, Miller TD. Recurrent Cardioembolic Strokes Due to Marantic Endocarditis As the Initial Presentation of Colorectal Adenocarcinoma. Cureus 2022; 14:e24183. [PMID: 35592190 PMCID: PMC9110090 DOI: 10.7759/cureus.24183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/15/2022] [Indexed: 11/05/2022] Open
Abstract
Metastases to the brain from primary colorectal carcinoma are rare. Existing literature describing cranial nerve palsy from metastatic colorectal cancer is scattered. To our knowledge, we are the first to describe the combination of CN deficits V, VII, and XII as the initial presentation of colorectal malignancy. The authors present the case of a patient with no past medical history who presented with multiple cranial nerve deficits of the right trigeminal, facial, and hypoglossal nerves. MRI of the brain revealed a mass in Meckel's cave, which explained the involvement of the trigeminal nerve (CN V) but not the facial (CN VII) and hypoglossal (CN XII) nerves. Further workup revealed multiple cardioembolic strokes caused by nonbacterial thrombotic endocarditis (NBTE). Extensive workup for the cause of his NBTE and subsequent cerebrovascular events revealed colorectal adenocarcinoma.
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9
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Liu Y, Li X, Song F, Yan X, Han Z, Tang F, Li Y. Clinical Features and Prognostic Factors of Acute Ischemic Stroke Related to Malignant Gastrointestinal Tumor. Front Neurol 2021; 12:777483. [PMID: 34899584 PMCID: PMC8655855 DOI: 10.3389/fneur.2021.777483] [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: 09/15/2021] [Accepted: 10/07/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives: To analyze the clinical and imaging features of acute ischemic stroke (AIS) related to gastrointestinal malignant tumor, and to explore the prognostic factors. Methods: Clinical data of consecutive patients with gastrointestinal malignant tumor complicated with AIS admitted to the Department of Neurology and Oncology in Lanzhou University Second Hospital from April 2015 to April 2019 were retrospectively analyzed. Patients were divided into good prognosis (mRS 0–2) and poor prognosis (mRS > 2) based on a 90-day mRS score after discharge. The multivariate logistic regression model was used to analyze the prognostic factors. Results: A total of 68 patients were enrolled with an average age of 61.78 ± 6.65 years, including 49 men (72.06%). There were 18 patients in the good prognosis group and 50 patients in the poor prognosis group. The univariate analysis showed that Hcy, D-dimer, thrombin–antithrombin complex (TAT), and three territory sign in magnetic resonance imaging (MRI) were the risk factors for poor prognosis. Multivariate analysis showed that increased D-dimer (OR 4.497, 95% CI 1.014–19.938) and TAT levels (OR 4.294, 95% CI 1.654–11.149) were independent risk factors for the prognosis in such patients. Conclusion: Image of patients with gastrointestinal malignant tumor-related AIS is characterized by three territory sign (multiple lesions in different vascular supply areas). Increased TAT and D-dimer levels are independent prognostic risk factors. TAT is more sensitive to predict prognosis than D-dimer.
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Affiliation(s)
- Yating Liu
- Department of Oncology, Lanzhou University Second Hospital, Lanzhou, China.,Key Laboratory of the Digestive System Tumors of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
| | - Xin Li
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, China
| | - Feixue Song
- Department of Oncology, Lanzhou University Second Hospital, Lanzhou, China
| | - Xin Yan
- Key Laboratory of the Digestive System Tumors of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
| | - Zhijian Han
- Key Laboratory of the Digestive System Tumors of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
| | - Futian Tang
- Key Laboratory of the Digestive System Tumors of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
| | - Yumin Li
- Key Laboratory of the Digestive System Tumors of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
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10
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Finelli PF. MR Three-Territory Sign in Cancer-Associated Hypercoagulation Stroke (Trousseau Syndrome): An Overlooked Diagnostic Feature: MR Three-Territory Sign. Neurologist 2021; 27:37-40. [PMID: 34842569 DOI: 10.1097/nrl.0000000000000356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Stroke in the setting of three-territory lesion pattern on magnetic resonance-diffusion-weighted imaging "three-territory sign" (TTS) is predominately due to cancer-associated hypercoagulation (CAH). Our goal is to determine the frequency with which "TTS" is overlooked as a diagnostic feature of cancer-associated hypercoagulation stroke. METHODS Over a 4-year period (October 2016 to October 2020), stroke admissions with magnetic resonance imaging defined three-territory diffusion-weighted imaging lesions were identified. Patients were prospectively accrued in an observational study from the neurology service at Hartford Hospital, a 938 bed facility with a comprehensive stroke center with 2792 stroke admissions during the study period. RESULTS Twenty-two patients met selection criteria, 4 due to infectious endocarditis, 16 due to stroke from CAH and 2 with no identifiable etiology. Of the 16 CAH patients, 5 were male and 11 female, mean age=72 (range: 47 to 91). Cancer type (biopsy proven unless noted) was cholangiocarcinoma=3, adenocarcinoma of lung=3, adenocarcinoma of breast=1, pancreatic carcinoma=3 (2 biopsy, 1 ultrasound), adenocarcinoma, origin unknown=1, non-small cell carcinoma of lung=2, carcinoid=1, ovarian carcinoma=1, lung mass (not biopsied)=1. Malignancy was known in 7 and occult in 9 at stroke presentation. Consideration of malignancy-related hypercoagulation as the cause of stroke was appreciated in 1 of 16 radiology reports and in 4 of 16 neurology admission notes. CONCLUSION TTS is a frequently missed diagnostic magnetic resonance feature in cancer-associated hypercoagulation stroke and often heralds occult malignancy.
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Affiliation(s)
- Pasquale F Finelli
- Department of Neurology, Hartford Hospital and University of Connecticut School of Medicine, Hartford, CT
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11
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Ischemic Stroke in Patients with Cancer: a Retrospective Cross-Sectional Study. J Crit Care Med (Targu Mures) 2021; 7:54-61. [PMID: 34722904 PMCID: PMC8519371 DOI: 10.2478/jccm-2021-0002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/05/2021] [Indexed: 12/21/2022] Open
Abstract
Introduction An increasing trend of cancer associated stroke has been noticed in the past decade. Objectives To evaluate the risk factors and the incidence of neoplasia in stroke patients. Material and Method A retrospective, observational study was undertaken on 249 patients with stroke and active cancer (SAC) and 1563 patients with stroke without cancer (SWC). The general cardiovascular risk factors, the site of cancer, and the general clinical data were registered and evaluated. According to the “Oxfordshire Community Stroke Project” (OCSP) classification, all patients were classified into the clinical subtypes of stroke. The aetiology of stroke was considered as large-artery atherosclerosis, small vessel disease, cardio-embolic, cryptogenic or other determined cause. Results The severity of neurological deficits at admission were significantly higher in the SAC group (p<0.01). The haemoglobin level was significantly lower, and platelet level and erythrocyte sedimentation rate were significantly higher in the SAC group. Glycaemia, cholesterol and triglycerides levels were significantly higher in the SWC group. The personal history of hypertension was more frequent in the SWC group. In the SAC group, 28.9% had a cryptogenic aetiology, compared to 9.1% in SWC group. Cardio-embolic strokes were more frequent in the SAC group (24%) than the SWC group (19.6%). In the SAC group, 15,6% were diagnosed with cancer during the stroke hospitalization, and 78% of the SAC patients were without metastasis. Conclusions The most frequent aetiologies of stroke in cancer patients were cryptogenic stroke, followed by large-artery atherosclerosis. SAC patients had more severe neurological deficits and worse clinical outcomes than SWC patients. Stroke in cancer patients appears to be more frequently cryptogenic, probably due to cancer associated thrombosis. The association between stroke and cancer is important, especially in stroke of cryptogenic mechanism, even in the presence of traditional cardiovascular risk factors.
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12
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Ling Y, Li Y, Zhang X, Dong L, Wang J. Clinical features of Trousseau's syndrome with multiple acute ischemic strokes. Neurol Sci 2021; 43:2405-2411. [PMID: 34564800 DOI: 10.1007/s10072-021-05619-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Trousseau's syndrome or migrating thrombophlebitis can cause venous or arterial thrombosis; however, multiple acute ischemic strokes (MAIS) caused by Trousseau's syndrome are rare. The aim of this study was to analyse the clinical features of Trousseau's syndrome with MAIS and to improve the awareness and the knowledge of this disease. METHODS Clinical data from fifteen patients who were diagnosed as Trousseau's syndrome with MAIS in Rizhao People's Hospital from January 2017 to April 2020 were collected and analysed. The clinical data included the following: patients' basic information (including gender, age, underlying diseases, and tumour stage), laboratory results, imaging features, treatment regimens, and short-term prognoses were collected. RESULTS The mean age was 65.5 years, with thirteen males and two females. Most patients (11/15) had a history of smoking and (or) drinking. The average score of NIHSS was 2.13. 6 of the 15 patients first presented with ischemic stroke and then found the primary tumour. Most common types of primary tumour was lung cancer (11/15), and other types of primary tumour were gastric adenocarcinoma, renal cell carcinoma, oesophageal adenosquamous carcinoma, and cholangiocarcinoma (one in each). All the 15 patients showed different levels of increase of D-dimer. The increase in CRP appears in 10 of the 15 patients. Various tumour markers were increased in the 15 patients, especially for CYFRA-211, all the patients of which were higher than normal. All of the 15 patients had multiple vascular territory lesions in DWI, and most lesions were near the cortex areas. Only 4 of the 15 patients (26.7%) occurred with peripheral venous thrombosis. Thirteen patients were given low molecular heparin for anticoagulant therapy, of which 9 patients were improved in short-term while 4 patients were not. CONCLUSION Trousseau's syndrome with MAIS was associated with old-age male, smoking and (or) drinking history, low NIHSS score, increased D-dimer, CRP and tumour markers, and lesions near the cortex areas with multiple vascular territories in DWI. Patients with these features should be alert of malignant tumour. Most common types of primary tumour were lung cancer. Treatment with low molecular heparin may be effective in short term.
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Affiliation(s)
- Yitong Ling
- Department of Neurology, Rizhao People's Hospital, Rizhao, 276826, Shandong, China
| | - Yinye Li
- Department of Imaging, Donggang District People's Hospital of Rizhao, Rizhao, 276826, Shandong, China
| | - Xiaoyu Zhang
- 3Department of Emergency, Rizhao People's Hospital, Rizhao, 276826, Shandong, China
| | - Lihua Dong
- Department of Neurology, Rizhao People's Hospital, Rizhao, 276826, Shandong, China
| | - Jintao Wang
- Department of Neurology, Rizhao People's Hospital, Rizhao, 276826, Shandong, China.
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13
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Bando T, Ueno Y, Kuroyama T, Shimo D, Mikami K, Hori S, Tanaka Y, Hirai O. Histopathological diagnosis of clot tissues collected by mechanical thrombectomy provides understanding of cerebral infarction pathology in cancer associated thrombosis: A case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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14
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Kataoka Y, Sonoda K, Takahashi JC, Ishibashi-Ueda H, Toyoda K, Yakushiji Y, Kusaka H, Koga M. Histopathological analysis of retrieved thrombi from patients with acute ischemic stroke with malignant tumors. J Neurointerv Surg 2021; 14:neurintsurg-2020-017195. [PMID: 34050032 DOI: 10.1136/neurintsurg-2020-017195] [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: 12/17/2020] [Accepted: 05/18/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The procoagulant state in cancer increases the thrombotic risk, and underlying cancer could affect treatment strategies and outcomes in patients with ischemic stroke. However, the histopathological characteristics of retrieved thrombi in patients with cancer have not been well studied. This study aimed to assess the histopathological difference between thrombi in patients with and without cancer. METHODS We studied consecutive patients with acute major cerebral artery occlusion who were treated with endovascular therapy between October 2010 and December 2016 in our single-center registry. The retrieved thrombi were histopathologically investigated with hematoxylin and eosin and Masson's trichrome staining. The organization and proportions of erythrocyte and fibrin/platelet components were studied using a lattice composed of 10×10 squares. RESULTS Of the 180 patients studied, 17 (8 women, age 76.5±11.5 years) had cancer and 163 (69 women, age 74.1±11.2 years) did not. Those with cancer had a higher proportion of fibrin/platelets (56.6±27.4% vs 40.1±23.9%, p=0.008), a smaller proportion of erythrocytes (42.1±28.3% vs 57.5±25.1%, p=0.019), and higher serum D-dimer levels (5.9±8.2 vs 2.4±4.3 mg/dL, p=0.005) compared with the non-cancer cases. Receiver operating characteristic curve analysis showed the cut-off ratio of fibrin/platelet components related to cancer was 55.7% with a sensitivity of 74.8%, specificity 58.8% and area under the curve (AUC) value of 0.67 (95% CI 0.53 to 0.81), and the cut-off ratio of erythrocyte components was 44.7% with a sensitivity of 71.2%, specificity 58.9% and AUC value of 0.66 (95% CI 0.51 to 0.80). CONCLUSIONS Thromboemboli of major cerebral arteries in patients with cancer were mainly composed of fibrin/platelet-rich components.
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Affiliation(s)
- Yuko Kataoka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan .,Department of Neurology, Kansai Medical University, Hirakata, Osaka, Japan
| | - Kazutaka Sonoda
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.,Department of Neurology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Jun C Takahashi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.,Department of Neurosurgery, Kindai University Faculty of Medicine Hospital, Osaka-Sayama, Osaka, Japan
| | - Hatsue Ishibashi-Ueda
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.,Department of Pathology, Hokusetsu General Hospital, Takatsuki, Osaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yusuke Yakushiji
- Department of Neurology, Kansai Medical University, Hirakata, Osaka, Japan
| | - Hirofumi Kusaka
- Department of Neurology, Kansai Medical University, Hirakata, Osaka, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Huang CC, Yang YC, MacDonald I, Lai CY, Tu CH, Chen YH. Traditional Chinese Medicine Reduces the Incidence of Chemotherapy-Induced Stroke: A Five-Year Nationwide Population-Based Cohort Study From Taiwan. Front Pharmacol 2021; 12:614606. [PMID: 34122061 PMCID: PMC8187954 DOI: 10.3389/fphar.2021.614606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 05/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Chemotherapy is suspected to be a risk factor for stroke in patients with cancer, athough the results from large-scale studies are controversial. Few strategies are available for reducing the stroke-related risks. Methods: We analyzed stroke incidence rates in Taiwan’s Longitudinal Health Insurance database 2000 (LHID2000) for patients aged ≥20 years with newly-diagnosed cancer between Jan 1, 2000 and Dec 31, 2006, who did or did not receive chemotherapy. Moreover, we compared stroke incidence rates among chemotherapy users who did or did not use traditional Chinese medicine. All study participants were followed-up for 5 years or until they had a stroke. Results: In adjusted Kaplan-Meier analysis, the incidence of stroke was higher within the first year of cancer diagnosis among chemotherapy recipients compared with those who did not receive chemotherapy (31.1 vs. 9.75; adjusted subdistribution hazard ratio [sHR] 2.21; 95% confidence interval [CI], 1.52–3.20; p < 0.001). This between-group difference persisted at 4 years of follow-up (13.6 vs. 5.42; adjusted sHR 1.94; 95% CI, 1.53–2.46; p < 0.001). Similarly, the 5-year incidence rate of stroke was significantly lower among chemotherapy recipients using TCM vs. non-TCM users (0.19 vs. 0.46; adjusted sHR 0.45; 95% CI, 0.26–0.79; p < 0.001), as was the mortality rate (adjusted sHR 0.55; 95% CI, 0.44–0.68; p < 0.001). Conclusion: These Taiwanese data suggest that chemotherapy is a risk factor for stroke and that the use of TCM can significantly mitigate this risk. TCM also appears to reduce the mortality risk associated with chemotherapy.
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Affiliation(s)
- Chien-Chen Huang
- Graduate Institute of Chinese Medicine, School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan.,Department of Traditional Chinese Medicine, An Nan Hospital, China Medical University, Tainan, Taiwan
| | - Yu-Cih Yang
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Iona MacDonald
- Graduate Institute of Acupuncture Science, China Medical University, Taichung, Taiwan
| | - Ching-Yuan Lai
- Center for Emergency and Critical Care Medicine, China Medical University Beigang Hospital, Yunlin, Taiwan
| | - Cheng-Hao Tu
- Graduate Institute of Acupuncture Science, China Medical University, Taichung, Taiwan
| | - Yi-Hung Chen
- Graduate Institute of Acupuncture Science, China Medical University, Taichung, Taiwan.,Department of Photonics and Communication Engineering, Asia University, Taichung, Taiwan
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16
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Zhen C, Wang Y, Wang H, Li D, Wang X. Multiple cerebral infarction linked to underlying cancer: a review of Trousseau syndrome-related cerebral infarction. Br J Hosp Med (Lond) 2021; 82:1-7. [PMID: 34076507 DOI: 10.12968/hmed.2020.0696] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Trousseau syndrome is a cancer-associated hypercoagulative state leading to venous or arterial thromboembolic events. Cerebral infarction is the most common result of arterial embolism and the pathogenesis is complicated, mainly associated with hypercoagulation and non-bacterial thrombotic endocarditis. On magnetic resonance imaging, multiple lesions are dispersed in more than two territories of the brain, often simultaneously involving the bilateral anterior and posterior circulation. Elevated plasma levels of D-dimer and fibrinogen degradation products may be seen in these patients. There are high rates of short-term recurrence of stroke and sudden death, highlighting the need for early recognition and appropriate treatment of Trousseau syndrome-associated cerebral infarction.
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Affiliation(s)
- Chao Zhen
- Department of Neurology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, People's Republic of China
| | - Yabo Wang
- Department of Emergency, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, People's Republic of China
| | - Haifeng Wang
- Department of Neurology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, People's Republic of China
| | - Dongmei Li
- Department of Neurology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, People's Republic of China
| | - Xin Wang
- Department of Neurology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, People's Republic of China
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Abstract
Cancer and cancer therapies have the potential to affect the nervous system in a host of different ways. Cerebral edema, increased intracranial pressure, cerebrovascular events, status epilepticus, and epidural spinal cord compression are among those most often presenting as emergencies. Neurologic side-effects of cancer therapies are often mild, but occasionally result in serious illness. Immunotherapies cause autoimmune-related neurologic side-effects that are generally responsive to immunosuppressive therapies. Emergency management of neuro-oncologic problems benefits from early identification and close collaboration among interdisciplinary team members and patients or surrogate decision-makers.
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Affiliation(s)
- Zachary D Threlkeld
- Division of Neurocritical Care, Department of Neurology, Stanford University School of Medicine, 300 Pasteur Drive MC 5778, Stanford, CA 94305, USA
| | - Brian J Scott
- Division of Neurohospitalist Medicine, Department of Neurology, Stanford University School of Medicine, 453 Quarry Rd, 2nd Floor, Stanford, CA 94305, USA.
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18
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Risk of Cancer Following an Ischemic Stroke in the Canadian Longitudinal Study on Aging. Can J Neurol Sci 2021; 49:225-230. [PMID: 33766161 DOI: 10.1017/cjn.2021.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Stroke survivors may be at higher risk of incident cancer, although the magnitude and the period at risk remain unclear. We conducted a retrospective cohort study to compare the risk of cancer in stroke survivors to that of the general population. METHODS The Canadian Longitudinal Study on Aging is a large population-based cohort of individuals aged 45-85 years when recruited (2011-2015). We used data from the comprehensive subgroup (n = 30,097) to build a retrospective cohort with individual exact matching for age (1:4 ratio). We used Cox proportional hazards models to estimate hazard ratios of new cancer diagnosis with and without a prior stroke. RESULTS We respectively included 920 and 3,680 individuals in the stroke and non-stroke groups. We observed a higher incidence of cancer in the first year after stroke that declined afterward (p-value = 0.030). The hazard of new cancer diagnosis after stroke was significantly increased (hazard ratio: 2.36; 95% CI: 1.21, 4.61; p-value = 0.012) as compared to age-matched non-stroke participants after adjustments. The most frequent primary cancers in the first year after stroke were prostate (n = 8, 57.1%) and melanoma (n = 2, 14.3%). CONCLUSIONS The hazard of new cancer diagnosis in the first year after an ischemic stroke is about 2.4 times higher as compared to age-matched individuals without stroke after adjustments. Surveillance bias may explain a portion of post-stroke cancer diagnoses although a selection bias of healthier participants likely led to an underestimation of post-stroke cancer risk. Prospective studies are needed to confirm the potentially pressing need to screen for post-stroke cancer.
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19
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Holt JN. A case of multifocal stroke-the first presentation of underlying ovarian malignancy. J Surg Case Rep 2021; 2021:rjaa550. [PMID: 33569161 PMCID: PMC7852472 DOI: 10.1093/jscr/rjaa550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 12/03/2020] [Indexed: 11/23/2022] Open
Abstract
Ischaemic stroke is a rare manifestation of hypercoagulability induced by underlying malignancy. It is proposed that paraneoplastic non-bacterial thrombotic endocarditis (NBTE) is the most common cause, predisposing to the formation of friable valvular lesions composed of platelets and fibrin that embolize commonly. Pancreas, gallbladder, stomach, colon and gynaecological malignancies have all been associated with NBTE. We describe a female patient who presented to our facility with syncope and limb weakness. Magnetic resonance imaging of the brain revealed ischaemic strokes in both the anterior and posterior circulation. Further investigation revealed a pelvic mass that was biopsy proven to be ovarian malignancy. Prognosis is heavily reliant on disease stage, thus diagnostic clues suggesting the possibility of underlying malignancy in the presentation of stroke should prompt a thorough investigation to exclude malignancy.
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Affiliation(s)
- Jonathon N Holt
- General Surgical Department, Albury-Wodonga Health, Albury, NSW, Australia
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20
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Wu S, Xing Z, Lin J, Cui F, Liu H. Tumor metastasis has a significant relationship with the development of acute ischemic stroke in Chinese cancer patients: a retrospective study. J Int Med Res 2021; 49:300060520986298. [PMID: 33478293 PMCID: PMC7841866 DOI: 10.1177/0300060520986298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 12/11/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE This study was designed to analyze the relationship between tumor metastasis and acute ischemic stroke (AIS) in Chinese cancer patients. METHODS This retrospective study included 119 cancer patients with AIS and 152 cancer patients without AIS. Basic information was collected and tumor metastasis status was determined for all patients. RESULTS The whole cohort had a median age of 59 (49-69) years with 150 men (55.4%). There were 98 patients (36.2%) with tumor metastasis. Patients with AIS had significantly more males, tumor metastasis, lung cancer, hypertension, diabetes mellitus, higher age, D-dimer, international normalized ratio, prothrombin time, prothrombin activity, and thrombin time, while they had significantly lower levels of hemoglobin, red blood cells, and hematocrit. In multivariate logistic regression analysis, AIS was significantly and positively associated with age, tumor metastasis, D-dimer, and thrombin time. In multivariate Cox regression analysis, tumor metastasis, AIS, D-dimer, thrombin time, and fibrinogen were significantly and positively associated with worse prognosis. CONCLUSIONS This study demonstrates that tumor metastasis was positively and independently associated with AIS in Chinese cancer patients, suggesting that tumor metastasis has a significant relationship with the development of AIS. Additionally, tumor metastasis and AIS had negative independent effects on the prognosis of patients.
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Affiliation(s)
- Siting Wu
- Neurology Department, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, China
| | - Zengluan Xing
- Neurology Department, Cadre Sanatorium of Hainan (Geriatric Hospital of Hainan), Haikou, China
| | - Jiacai Lin
- Neurology Department, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, China
| | - Fang Cui
- Neurology Department, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, China
| | - Hui Liu
- Oncology Department, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, China
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21
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Trousseau's syndrome associated with rapidly emerging pancreatic adenocarcinoma soon after esophagectomy: A case report. Int J Surg Case Rep 2020; 77:605-609. [PMID: 33395856 PMCID: PMC7708758 DOI: 10.1016/j.ijscr.2020.11.113] [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: 11/06/2020] [Revised: 11/18/2020] [Accepted: 11/18/2020] [Indexed: 11/20/2022] Open
Abstract
The first reported case of Trousseau’s syndrome associated with rapidly emerging pancreatic cancer potentially triggered esophagectomy. The aggressively emerging pancreatic cancer with mucin production may be a potential mechanism for cancer-related thrombosis. When a patient with cancer encountered small, multiple cerebral infarctions postoperatively, the body should be checked for occult malignancy.
Introduction Trousseau’s syndrome is characterized as an unexpected, cancer-associated thrombotic event. We describe the first reported case of Trousseau’s syndrome associated with rapidly emerging pancreatic cancer potentially triggered by esophagectomy. Presentation of case A 79-year-old asymptomatic male with clinical stage I esophageal squamous cell carcinoma underwent thoracoscopic subtotal esophagectomy. On postoperative day 46, the patient presented with weakness of his left upper extremity due to multiple cerebral and cerebellar infarctions, with no evidence of atherosclerotic or cardiogenic thrombi. An abdominal computed tomography (CT) showed a pancreatic tumor with multiple liver metastases. Extremely high D-dimer and the CT findings suggested Trousseau’s syndrome associated with a rapidly emerging neoplasm as the etiology of the brain infarction. Although further thrombotic events did not occur, his condition deteriorated rapidly and died on the 31st days of onset. The autopsy revealed multiple small infarctions, with multiple thrombi in the cerebral hemispheres, brain stem, and cerebellum. Histological evaluation revealed pancreatic adenocarcinoma with nodal and liver metastases. Discussion A hypercoagulable state associated with the aggressively emerging pancreatic adenocarcinoma, accompanied by cancer cell production of mucin, may be a potential mechanism for cancer-related thrombosis. Conclusion In patients who received intensive surgical treatment and encountered unexplained brain infarctions in the multi-arterial territory, Trousseau’s syndrome should be considered, and investigation for occult malignancy is required.
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22
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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: 2] [Impact Index Per Article: 0.5] [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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Goel D, Sharma V, Pran MM, Gupta R, Keshri T, Shettigar U. A case of recurrent stroke with underlying adenocarcinoma: Pseudo-cryptogenic stroke. Brain Circ 2020; 6:126-129. [PMID: 33033783 PMCID: PMC7511917 DOI: 10.4103/bc.bc_49_19] [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: 11/04/2019] [Revised: 02/24/2020] [Accepted: 03/17/2020] [Indexed: 11/24/2022] Open
Abstract
Stroke is the most common neurological disorders leading to early death. Early recognition of underlying mechanisms and etiology of stroke is important to prevent recurrence, mortality and disability. The term cryptogenic stroke or embolic stroke of undetermined sources is used where no etiology could be detected. We are describing this rare case of “recurrent stroke with undetermined etiology” finally proved to have an uncommon underlying etiology.
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Affiliation(s)
- Deepak Goel
- Department of Neurology, Himalayan Institute of Medical Sciences, Swami Ram Himalayan University, Dehradun, Uttarakhand, India
| | - Vikram Sharma
- Department of Neurology, Max Institute of Neurosciences, Dehradun, Uttarakhand, India
| | - Madasu Mukhiya Pran
- Department of Radiology, Max Institute of Neurosciences, Dehradun, Uttarakhand, India
| | - Rekha Gupta
- Department of Neuro-Critical Care, Max Institute of Neurosciences, Dehradun, Uttarakhand, India
| | - Tulika Keshri
- Department of Neurology, Max Institute of Neurosciences, Dehradun, Uttarakhand, India
| | - Uttam Shettigar
- Department of Neurology, Max Institute of Neurosciences, Dehradun, Uttarakhand, India
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Yoo J, Choi JK, Kim YD, Nam HS, Park H, Lee HS, Heo JH. Outcome of Stroke Patients with Cancer and Nonbacterial Thrombotic Endocarditis. J Stroke 2020; 22:245-253. [PMID: 32635688 PMCID: PMC7341006 DOI: 10.5853/jos.2020.00619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/21/2020] [Indexed: 12/23/2022] Open
Abstract
Background and Purpose Nonbacterial thrombotic endocarditis (NBTE) is a cause of stroke in cancer. However, clinical characteristics and outcomes in stroke patients with cancer-associated NBTE are not well known. Methods We included consecutive patients with stroke and active cancer over a 9-year period who underwent echocardiography. We retrospectively compared clinical characteristics and presence of metastasis between patients with NBTE, those with cryptogenic etiologies, and those with determined etiologies. We also investigated mortality and stroke events during the 6-month follow-up. Results Among the 245 patients, 20 had NBTE, 96 had cryptogenic etiologies, and 129 had determined etiologies. Metastasis was seen in all 20 patients (100%) with NBTE, 69.8% in patients with cryptogenic etiology, and 48.8% in patients with or determined etiology. During the 6-month follow-up, 127 patients (51.8%) developed stroke and/or died (death in 110 [44.9%] and stroke events in 55 [22.4%]). Patients with NBTE showed significantly higher mortality (80%) and stroke occurrence (50%) than those with cryptogenic etiologies (mortality 54.2%, stroke 25.0%, log-rank P=0.006) and determined etiologies (mortality 32.6%, stroke 16.3%, log-rank P<0.001). In a multivariate Cox proportional hazard analysis, the presence of NBTE was independently associated with composite outcomes of mortality and stroke events (hazard ratio, 1.941; 95% confidence interval, 1.052 to 3.690). Conclusions NBTE should be suspected as a potential cause of stroke in patients with metastatic cancer. Patients with NBTE have a high risk of recurrent stroke and mortality. Future studies are necessary to determine strategies to reduce stroke recurrence in patients with NBTE.
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Affiliation(s)
- Joonsang Yoo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea.,Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyo Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Hyungjong Park
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
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Guo L, Wang L, Liu W. Ability of the number of territories involved on DWI-MRI to predict occult systemic malignancy in cryptogenic stroke patients. J Stroke Cerebrovasc Dis 2020; 29:104823. [PMID: 32362555 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/01/2020] [Accepted: 03/19/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Lesions in multiple arterial territories is one of the typical features of malignancy patients with cryptogenic stroke. Hence, if patients with cryptogenic stroke display such feature, occult cancer could be predicted. The study aimed to analyze the predictive ability of the number of territories involved on DWI-MRI for occult systemic malignancy (OSM) in patients with cryptogenic stroke. METHODS We enrolled patients with cryptogenic stroke without a diagnosis of malignancy at stroke onset between January 2013 and November 2018. Clinical variables were analyzed between cryptogenic stroke patients with and without OSM through univariate and multiple logistic regression analyses. Points for OSM were generated by β-coefficients. The sensitivity and specificity of the risk score were assessed by the area under the receiver operating characteristic curve (AUROC). The cutoff value for predicting OSM was determined by the maximum Youden index. RESULTS Among 108 cyptogenic stroke patients, compared to patients without OSM (n = 96), patients with OSM (n = 12) had a lower nutrition status (P = 0.031), higher plasma D-dimer levels (P < 0.001) and more territories involved on DWI-MRI (P < 0.001). Multiple logistic regression analysis revealed that plasma D-dimer levels (OR, 3.54; 95% Cl, 1.62-7.76; P = 0.002) and the number of territories involved (OR, 4.45; 95% CI, 1.25-15.80; P = 0.021) independently predicted OSM. The predictive score system built upon the number of territories showed good discrimination with an AUROC of 0.84 (95% CI, 0.71-0.96). The cutoff value was 2 with a maximum Youden's index of 0.56, which means that patients with more than one territory involved on DWI-MRI may need extensive screening for OSM. CONCLUSIONS The number of territories involved on DWI-MRI was a valid predictor for OSM in cryptogenic stroke patients who need to undergo further evaluations .
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Affiliation(s)
- Linjia Guo
- Department of Neurology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.
| | - Lili Wang
- Department of Neurology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Wenhong Liu
- Department of Neurology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Tybjerg AJ, Skyhøj Olsen T, Andersen KK. Prevalence and risk of occult cancer in stroke. Acta Neurol Scand 2020; 141:204-211. [PMID: 31701519 DOI: 10.1111/ane.13192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 09/05/2019] [Accepted: 09/13/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Cancer is associated with higher risk of stroke. Whether this translates into higher risk of cancer in stroke of an extent calling for cancer screening in stroke is unclear. We investigated prevalence and risk of occult cancer in stroke compared to the background population without history of stroke. MATERIALS AND METHODS All patients >40 years of age with incident stroke in Denmark 2003-2015 were identified through the Danish Stroke Registry (n = 85 893) and matched 1:10 on age and sex to the Danish background population without history of stroke (n = 858 740). Linking data to the Danish Cancer Registry, we determined prevalence of occult cancer in stroke defined as the event of previously unknown cancer during a 1-year follow-up in the stroke and in the background population. Cox regression models were used to study risk in comparison to the background population. RESULTS Prevalence (per 1000) of occult cancer in the stroke/background cohorts was 25.0/15.8 in women and 29.8/20.4 in men. Prevalence was dependent on age and sex. Highest among stroke patients aged 70-80 years (35.6 in women, 42.4 in men); lowest in patients aged 40-50 years (8.3 in women, 6.8 in men). Stroke was associated with an overall 54% higher risk of occult cancer but risk increased significantly with smoking, hazard ratio (HR) 1.47, age HR 1.27 per 10 years, male sex HR 1.25, and diabetes HR 1.25. CONCLUSIONS Prevalence and risk of occult cancer in stroke is considerable and calls for attention when designing the stroke investigation program.
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Affiliation(s)
| | - Tom Skyhøj Olsen
- Department of Neurology Bispebjerg University Hospital Copenhagen Denmark
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Shen Y, Li Y, Chen C, Wang W, Li T. D-dimer and diffusion-weighted imaging pattern as two diagnostic indicators for cancer-related stroke: A case-control study based on the STROBE guidelines. Medicine (Baltimore) 2020; 99:e18779. [PMID: 31977868 PMCID: PMC7004795 DOI: 10.1097/md.0000000000018779] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The aim of this study was to evaluate the risk factors and elucidate the clinical characteristics of cancer-associated ischemic stroke to differentiate it from conventional ischemic stroke in China and East Asia. Between June 2012 and June 2016, a retrospective analysis was performed on 609 stroke patients with cancer. They were divided into 3 groups: cancer-stroke group (CSG, 203 cases), stroke group (SG, 203 cases), and cancer group (CG, 203 cases). The D-dimer levels and diffusion-weighted imaging lesion (DWI) pattern were compared to an age- and sex-matched control group. The most common cancer types were colorectal cancer (20.2%) and lung cancer (18.72%). The average D-dimer level in stroke patients and cancer patients were 0.34 and 1.50 mg/L, respectively. The descending levels of D-dimer from cancer types were lung cancer (2.06 mg/L), pancreas (1.74 mg/L), gastric (1.61 mg/L), among others. Univariate analysis of the CSG and the others shows there were significant differences in the prevalence of the levels of D-dimer and DWI pattern, hypertension, diabetes mellitus, and thrombus. CSG has a unique pathological characteristic including high plasma D-dimer levels and multiple vascular lesions. The results show that D-dimer and DWI can be used as diagnostic index in clinical practice.
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Affiliation(s)
- Yijun Shen
- Department of Neurology, Xin Hua Hospital Chongming Branch Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai
- Department of Neurology, Xin Hua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai
| | - Yuxia Li
- Department of General Surgery, Hanchuan People's Hospital, Hanchuan
| | - Chengming Chen
- Department of Otorhinolaryngology, 900th Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Wenan Wang
- Department of Neurology, Xin Hua Hospital Chongming Branch Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai
- Department of Neurology, Xin Hua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai
| | - Tian Li
- Department of Neurology, Xin Hua Hospital Chongming Branch Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai
- School of Basic Medicine, The Fourth Military Medical University, 169 Changle West Road, Xi’an
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29
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Tsushima M, Metoki N, Hagii J, Saito S, Shiroto H, Yasujima M, Kato T, Kudo N, Toyama Y, Yokono Y, Nozaka M, Kawamura Y, Nakata M, Tomita H. D-dimer and C-reactive Protein as Potential Biomarkers for Diagnosis of Trousseau's Syndrome in Patients with Cerebral Embolism. J Stroke Cerebrovasc Dis 2019; 29:104534. [PMID: 31810721 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104534] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 11/09/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Differentiating stroke due to Trousseau's syndrome from other types of cerebral embolism is challenging, especially in patients with occult cancer. The current study aimed to determine predicting factors and biomarkers of stroke due to Trousseau's syndrome. METHODS This retrospective study comprised 496 consecutive patients with acute cerebral embolism, including 19, 85, 310, and, 82 patients with stroke due to Trousseau's syndrome, artery-to-artery embolism, cardioembolic stroke, and embolic stroke with undetermined source, respectively. All patients were evaluated within 72 hours of onset. The clinical characteristics, laboratory findings, and patterns on diffusion-weighted magnetic resonance imaging (DWI) were compared among the groups. RESULTS Plasma D-dimer and C-reactive protein (CRP) levels were significantly higher in the Trousseau's syndrome than in the other causes of cerebral embolism. Multivariate analyses demonstrated that female sex, multiple lesions on DWI, high D-dimer and CRP levels, and low platelet and low brain natriuretic peptide levels were independent predictors that could distinguish Trousseau's syndrome from the other causes of cerebral embolism. The cutoff values of D-dimer and CRP to identify stroke due to Trousseau's syndrome was 2.68 µg/mL fibrinogen equivalent units and .29 mg/dL, respectively. CONCLUSIONS The elevated D-dimer and CRP levels on admission in addition to specific clinical features may be useful for diagnosis of Trousseau's syndrome in patients with cerebral embolism.
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Affiliation(s)
- Michiko Tsushima
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | | | - Joji Hagii
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, Japan
| | - Shin Saito
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, Japan
| | | | | | - Tomo Kato
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Natsumi Kudo
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuichi Toyama
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yoshikazu Yokono
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Masashi Nozaka
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yosuke Kawamura
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Masamichi Nakata
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hirofumi Tomita
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; Department of Stroke and Cerebrovascular Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
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Potugari BR, Priyanka P, Komanapalli SD, Mercier RJ. Ovarian Cancer Presenting as Cryptogenic Stroke from Patent Foramen Ovale. Clin Med Res 2019; 17:97-101. [PMID: 31324738 PMCID: PMC6886892 DOI: 10.3121/cmr.2019.1444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 04/15/2019] [Accepted: 05/13/2019] [Indexed: 12/21/2022]
Abstract
A woman, aged 52 years, experienced severe headache, confusion, nausea, dizziness, and diplopia for three days. Magnetic resonance imaging of the brain showed multiple acute and subacute infarcts suggestive of embolic events. Dermatological examination was notable for splinter hemorrhages and macular patches on the fingernails and feet, respectively. Further diagnostic imaging of the chest and abdomen revealed pulmonary emboli and an ovarian mass with omental deposits and splenic infarcts. Fine-needle aspiration cytology and surgery confirmed a diagnosis of high-grade serous adenocarcinoma of the ovary with clear cell features. Extensive evaluation for malignancy should be considered on a case-by-case basis for patients with thromboembolic disease and an initial negative diagnostic evaluation for stroke. Consideration of patent foramen ovale closure is reasonable in patients with malignancy who are at risk for recurrent strokes.
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Affiliation(s)
- Bindu R Potugari
- Department of Internal Medicine, Marshfield Clinic, Marshfield, Wisconsin; Current affiliation: Oncology Fellow, St. Joseph Mercy Ann Arbor, Ypsilanti, Michigan
| | - Priyanka Priyanka
- Department of Internal Medicine, Marshfield Medical Center, Marshfield, Wisconsin; Current affiliation: Department of Internal Medicine, University of West Virginia, Morgantown, West Virginia
| | - Sarah D Komanapalli
- Department of Hospital Medicine, Marshfield Medical Center, Marshfield, Wisconsin
| | - Richard J Mercier
- Department of Oncology, Marshfield Medical Center, Marshfield, Wisconsin
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Navi BB, Mathias R, Sherman CP, Wolfe J, Kamel H, Tagawa ST, Saxena A, Ocean AJ, Iadecola C, DeAngelis LM, Elkind MSV, Hull H, Jickling GC, Sharp FR, Ander BP, Stamova B. Cancer-Related Ischemic Stroke Has a Distinct Blood mRNA Expression Profile. Stroke 2019; 50:3259-3264. [PMID: 31510897 PMCID: PMC6817410 DOI: 10.1161/strokeaha.119.026143] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background and Purpose- Comorbid cancer is common in patients with acute ischemic stroke (AIS). As blood mRNA profiles can distinguish AIS mechanisms, we hypothesized that cancer-related AIS would have a distinctive gene expression profile. Methods- We evaluated 4 groups of 10 subjects prospectively enrolled at 3 centers from 2009 to 2018. This included the group of interest with active solid tumor cancer and AIS and 3 control groups with active cancer only, AIS only, or vascular risk factors only. Subjects in the AIS-only and cancer-only groups were matched to subjects in the cancer-stroke group by age, sex, and cancer type (if applicable). Subjects in the vascular risk factor group were matched to subjects in the cancer-stroke and stroke-only groups by age, sex, and vascular risk factors. Blood was drawn 72 to 120 hours after stroke. Total RNA was processed using 3' mRNA sequencing. ANOVA and Fisher least significant difference contrast methods were used to estimate differential gene expression between groups. Results- In the cancer-stroke group, 50% of strokes were cryptogenic. All groups had differentially expressed genes that could distinguish among them. Comparing the cancer-stroke group to the stroke-only group and after accounting for cancer-only genes, 438 genes were differentially expressed, including upregulation of multiple genes/pathways implicated in autophagy signaling, immunity/inflammation, and gene regulation, including IL (interleukin)-1, interferon, relaxin, mammalian target of rapamycin signaling, SQSTMI1 (sequestosome-1), and CREB1 (cAMP response element binding protein-1). Conclusions- This study provides evidence for a distinctive molecular signature in blood mRNA expression profiles of patients with cancer-related AIS. Future studies should evaluate whether blood mRNA can predict detection of occult cancer in patients with AIS. Clinical Trial Registration- URL: https://clinicaltrials.gov. Unique identifier: NCT02604667.
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Affiliation(s)
- Babak B Navi
- From the Department of Neurology and Feil Family Brain and Mind Research Institute (B.B.N, R.M., C.P.S., H.K., C.I., L.M.D.), Weill Cornell Medicine, New York, NY
- Department of Neurology, Memorial Sloan Kettering, New York, NY (B.B.N, J.W., L.M.D.)
| | - Ryna Mathias
- From the Department of Neurology and Feil Family Brain and Mind Research Institute (B.B.N, R.M., C.P.S., H.K., C.I., L.M.D.), Weill Cornell Medicine, New York, NY
| | - Carla P Sherman
- From the Department of Neurology and Feil Family Brain and Mind Research Institute (B.B.N, R.M., C.P.S., H.K., C.I., L.M.D.), Weill Cornell Medicine, New York, NY
| | - Julia Wolfe
- Department of Neurology, Memorial Sloan Kettering, New York, NY (B.B.N, J.W., L.M.D.)
| | - Hooman Kamel
- From the Department of Neurology and Feil Family Brain and Mind Research Institute (B.B.N, R.M., C.P.S., H.K., C.I., L.M.D.), Weill Cornell Medicine, New York, NY
| | - Scott T Tagawa
- Department of Medicine (S.T.T., A.S., A.J.O.), Weill Cornell Medicine, New York, NY
| | - Ashish Saxena
- Department of Medicine (S.T.T., A.S., A.J.O.), Weill Cornell Medicine, New York, NY
| | - Allyson J Ocean
- Department of Medicine (S.T.T., A.S., A.J.O.), Weill Cornell Medicine, New York, NY
| | - Costantino Iadecola
- From the Department of Neurology and Feil Family Brain and Mind Research Institute (B.B.N, R.M., C.P.S., H.K., C.I., L.M.D.), Weill Cornell Medicine, New York, NY
| | - Lisa M DeAngelis
- From the Department of Neurology and Feil Family Brain and Mind Research Institute (B.B.N, R.M., C.P.S., H.K., C.I., L.M.D.), Weill Cornell Medicine, New York, NY
- Department of Neurology, Memorial Sloan Kettering, New York, NY (B.B.N, J.W., L.M.D.)
| | - Mitchell S V Elkind
- Departments of Neurology (M.S.V.E.), Columbia University, New York, NY
- Epidemiology (M.S.V.E.), Columbia University, New York, NY
| | - Heather Hull
- Department of Neurology, University of California, Davis (H.H., G.C.J., F.R.S., B.P.A., B.S.)
| | - Glen C Jickling
- Department of Neurology, University of California, Davis (H.H., G.C.J., F.R.S., B.P.A., B.S.)
| | - Frank R Sharp
- Department of Neurology, University of California, Davis (H.H., G.C.J., F.R.S., B.P.A., B.S.)
| | - Bradley P Ander
- Department of Neurology, University of California, Davis (H.H., G.C.J., F.R.S., B.P.A., B.S.)
| | - Boryana Stamova
- Department of Neurology, University of California, Davis (H.H., G.C.J., F.R.S., B.P.A., B.S.)
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Ohara T, Farhoudi M, Bang OY, Koga M, Demchuk AM. The emerging value of serum D-dimer measurement in the work-up and management of ischemic stroke. Int J Stroke 2019; 15:122-131. [DOI: 10.1177/1747493019876538] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Elevated D-dimer levels are a marker of both thrombin formation and fibrinolysis. Currently D-dimer measurement is routinely used for ruling out venous thromboembolism and diagnosis/monitoring of disseminated intravascular coagulation. Recent emerging data suggest that D-dimer may become an important biomarker in ischemic stroke as well as in cardiovascular diseases. Aims To outline the clinical utility of D-dimer in work-up and management of ischemic stroke. Summary D-dimer measurement is most useful in stroke with active cancer as it can confirm etiologic diagnosis, predict recurrent stroke risk, and aid treatment decision in cancer-associated stroke. In cryptogenic stroke, high D-dimer levels can also provide clues for the cause of stroke as occult cancer and undetected cardiac embolic source as occult atrial fibrillation and may be helpful in treatment decision making of secondary stroke prevention. Serial D-dimer measurements should be further studied to monitor antithrombotic therapy effectiveness in both cardiogenic and cryptogenic etiologies. Conclusion Accumulating data suggests the utility of D-dimer test in the management of ischemic stroke, although the evidence is still limited. Future studies would clarify the role of D-dimer measurement in ischemic stroke.
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Affiliation(s)
- Tomoyuki Ohara
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine University of Calgary, Calgary, Canada
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Mehdi Farhoudi
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine University of Calgary, Calgary, Canada
- Neurosciences Research Center, Neurology Department, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Andrew M Demchuk
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine University of Calgary, Calgary, Canada
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Wei YC, Chen KF, Wu CL, Lee TW, Liu CH, Shyu YC, Lin CP. Stroke Rate Increases Around the Time of Cancer Diagnosis. Front Neurol 2019; 10:579. [PMID: 31231302 PMCID: PMC6566310 DOI: 10.3389/fneur.2019.00579] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/16/2019] [Indexed: 12/15/2022] Open
Abstract
Objective: To test whether strokes increase around the time of cancer diagnosis, we comprehensively examined the correlations of cancer and stroke by employing a population-based cohort study design. Methods: One million people insured under the Taiwan's National Health Insurance program in 2005 were randomly sampled to create the study's dataset. According to the presence of cancer and/or stroke, patients were separated into cancer and stroke, cancer-only, and stroke-only groups. Diagnoses of cancer, stroke, and comorbidities were defined according to ICD9-CM codes. Cancer and non-cancer populations were matched by age at cancer diagnosis, gender, and stroke risk factors, and each patient with cancer was matched with two non-cancer controls nested in the same year of cancer diagnosis. The hazards of stroke and cumulative incidences within a year after cancer diagnosis were evaluated using Fine and Gray's subdistributional hazard model. Results: The temporal distribution of first-ever stroke in patients with both cancer and stroke was a sharpened bell shape that peaked between 0.5 years before and after cancer diagnosis. Frequencies of stroke were further adjusted by number of cancer survivors. The monthly event rate of stroke remained nested around the time of cancer diagnosis in all strokes. Brain malignancies, lung cancer, gastric cancer, prostate cancer, and leukemia patients obtained higher ratio of stroke, while breast cancer and thyroid cancer patients had low percentage of combining stroke. When compared to non-cancer matched control, the hazard of stroke within one year after cancer diagnosis was increased by cancer at a subdistributional hazard ratio of 1.72 (95% confident interval 1.48 to 2.01; p < 0.0001). Conclusions: Cancer increased the risk of stroke and stroke events were nested around the time of cancer diagnosis, occurring 0.5 years prior to cancer on average regardless of stroke type.
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Affiliation(s)
- Yi-Chia Wei
- Department of Neurology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Keelung, Taiwan
- Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Kuan-Fu Chen
- Clinical Informatics and Medical Statistics Research Center, Chung Gung University, Taoyuan, Taiwan
- Department of Emergency, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chia-Lun Wu
- Department of Neurology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Keelung, Taiwan
| | - Tay-Wey Lee
- Biostatistical Consultation Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chi-Hung Liu
- Department of Neurology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Chiau Shyu
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ching-Po Lin
- Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan
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Dardiotis E, Aloizou AM, Markoula S, Siokas V, Tsarouhas K, Tzanakakis G, Libra M, Kyritsis AP, Brotis AG, Aschner M, Gozes I, Bogdanos DP, Spandidos DA, Mitsias PD, Tsatsakis A. Cancer-associated stroke: Pathophysiology, detection and management (Review). Int J Oncol 2019; 54:779-796. [PMID: 30628661 PMCID: PMC6365034 DOI: 10.3892/ijo.2019.4669] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 12/28/2018] [Indexed: 12/15/2022] Open
Abstract
Numerous types of cancer have been shown to be associated with either ischemic or hemorrhagic stroke. In this review, the epidemiology and pathophysiology of stroke in cancer patients is discussed, while providing vital information on the diagnosis and management of patients with cancer and stroke. Cancer may mediate stroke pathophysiology either directly or via coagulation disorders that establish a state of hypercoagulation, as well as via infections. Cancer treatment options, such as chemotherapy, radiotherapy and surgery have all been shown to aggravate the risk of stroke as well. The clinical manifestation varies greatly depending upon the underlying cause; however, in general, cancer‑associated strokes tend to appear as multifocal in neuroimaging. Furthermore, several serum markers have been identified, such as high D‑Dimer levels and fibrin degradation products. Managing cancer patients with stroke is a delicate matter. The cancer should not be considered a contraindication in applying thrombolysis and recombinant tissue plasminogen activator (rTPA) administration, since the risk of hemorrhage in cancer patients has not been reported to be higher than that in the general population. Anticoagulation, on the contrary, should be carefully examined. Clinicians should weigh the benefits and risks of anticoagulation treatment for each patient individually; the new oral anticoagulants appear promising; however, low‑molecular‑weight heparin remains the first choice. On the whole, stroke is a serious and not a rare complication of malignancy. Clinicians should be adequately trained to handle these patients efficiently.
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Affiliation(s)
- Efthimios Dardiotis
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | - Athina-Maria Aloizou
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | - Sofia Markoula
- Department of Neurology, University Hospital of Ioannina, 45110 Ioannina
| | - Vasileios Siokas
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | | | - Georgios Tzanakakis
- Laboratory of Anatomy-Histology-Embryology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Massimo Libra
- Department of Biomedical and Biotechnological Sciences, Pathology and Oncology Section, University of Catania, 95124 Catania, Italy
| | | | - Alexandros G. Brotis
- Department of Neurosurgery, University of Thessaly, University Hospital of Larissa, 41100 Larissa, Greece
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Illana Gozes
- The Lily and Avraham Gildor Chair for the Investigation of Growth Factors, The Elton Laboratory for Molecular Neuroendocrinology, Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Sagol School of Neuroscience and Adams Super Center for Brain Studies, Tel Aviv University, Tel Aviv 69978, Israel
| | - Dimitrios P. Bogdanos
- Department of Rheumatology and Clinical Immunology, University General Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 40500 Larissa
- Cellular Immunotherapy and Molecular Immunodiagnostics, Biomedical Section, Centre for Research and Technology-Hellas (CERTH) - Institute for Research and Technology-Thessaly (IRETETH), 41222 Larissa
| | | | - Panayiotis D. Mitsias
- Department of Neurology, School of Medicine, University of Crete, 71003 Heraklion, Greece
- Comprehensive Stroke Center and Department of Neurology, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Aristidis Tsatsakis
- Laboratory of Toxicology, School of Medicine, University of Crete, 71003 Heraklion, Greece
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Nouh AM, Staff I, Finelli PF. Three Territory Sign: An MRI marker of malignancy-related ischemic stroke (Trousseau syndrome). Neurol Clin Pract 2019; 9:124-128. [PMID: 31041126 DOI: 10.1212/cpj.0000000000000603] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/17/2018] [Indexed: 11/15/2022]
Abstract
Background Multiple acute cerebral territory infarcts of undetermined origin are typically attributed to cardioembolism, most frequently atrial fibrillation. However, the importance of 3-territory involvement in association with malignancy is under-recognized. We sought to highlight the "Three Territory Sign" (TTS) (bilateral anterior and posterior circulation acute ischemic diffusion-weighted imaging [DWI] lesions), as a radiographic marker of stroke due to malignancy. Methods We conducted a single-center retrospective analysis of patients from January 2014 to January 2016, who suffered an acute ischemic stroke with MRI-DWI at our institution, yielding 64 patients with a known malignancy and 167 patients with atrial fibrillation, excluding patients with both to eliminate bias. All DWI images were reviewed for 3-, 2-, and 1-territory lesions. Chi-square test of proportion was used to test significance between the 2 groups. Results We found an association between the groups (malignancy vs atrial fibrillation) and the number of territory infarcts (p < 0.0001). Pairwise comparisons using the Holm p value adjustment showed no difference between 1- and 2-territory patterns (p = 0.465). However, the TTS was 6 times more likely observed within the malignancy cohort as compared to patients with atrial fibrillation (23.4% [n = 15] vs 3.5% [n = 6]) and was different from both 1-territory (p < 0.0001) and 2-territory patterns (p = 0.0032). Conclusion The TTS is a highly specific marker and 6 times more frequently observed in malignancy-related ischemic stroke than atrial fibrillation-related ischemic stroke. Evaluation for underlying malignancy in patients with the TTS is reasonable in patients with undetermined etiology.
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Affiliation(s)
- Amre M Nouh
- Department of Neurology (AN, PFF) and Department of Research (IS), Hartford Hospital, Hartford, CT
| | - Ilene Staff
- Department of Neurology (AN, PFF) and Department of Research (IS), Hartford Hospital, Hartford, CT
| | - Pasquale F Finelli
- Department of Neurology (AN, PFF) and Department of Research (IS), Hartford Hospital, Hartford, CT
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Arterial thromboembolic events preceding the diagnosis of cancer in older persons. Blood 2018; 133:781-789. [PMID: 30578253 DOI: 10.1182/blood-2018-06-860874] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/14/2018] [Indexed: 01/03/2023] Open
Abstract
Cancer patients face an increased risk of arterial thromboembolism; however, it is uncertain when this excess risk begins. This study evaluated the risk of arterial thromboembolism before cancer diagnosis. Using the population-based Surveillance Epidemiology and End Results-Medicare linked dataset, we identified 374 331 patients ≥67 years of age with a new primary diagnosis of breast, lung, prostate, colorectal, bladder, uterine, pancreatic, gastric cancer, or non-Hodgkin lymphoma from 2005 through 2013. Cancer patients were individually matched by demographics and comorbidities to Medicare beneficiaries without cancer, who served as controls. Validated diagnosis codes were used to identify arterial thromboembolic events, defined as a composite of myocardial infarction or ischemic stroke. The Mantel-Haenszel estimator was used to compare risks of arterial thromboembolic events between cancer and noncancer groups during 30-day periods in the 360 days before date of cancer diagnosis. From 360 to 151 days before cancer diagnosis, the 30-day interval risks of arterial thromboembolic events were similar between cancer patients and matched controls. From 150 to 1 day before cancer diagnosis, the interval 30-day risks of arterial thromboembolic events were higher in cancer patients vs matched controls, progressively increasing as the cancer diagnosis date approached and peaking during the 30 days immediately before cancer diagnosis, when 2313 (0.62%) cancer patients were diagnosed with an arterial thromboembolic event vs 413 (0.11%) controls (odds ratio, 5.63; 95% confidence interval, 5.07-6.25). In conclusion, the risk of arterial thromboembolic events begins to increase 150 days before the date of cancer diagnosis in older persons and peaks in the 30 days before.
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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: 11] [Impact Index Per Article: 1.8] [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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Cacho-Díaz B, Spínola-Maroño H, Mendoza-Olivas LG. Clinical presentation, risk factors and outcome of central nervous system metastasis vs stroke in cancer patients. Curr Probl Cancer 2018; 43:324-330. [PMID: 30482399 DOI: 10.1016/j.currproblcancer.2018.09.001] [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: 09/05/2018] [Accepted: 09/24/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE Cancer and stroke are the second and third causes of death worldwide; brain metastases (BM) occur in one third of patients with cancer, any neurologic deficit in these population always prompts the clinician to discard metastases for their presence carries a bad outcome. Both might share clinical presentation and differences in their outcome are not entirely known. The aim was to compare risk factors, clinical presentation, and outcome of cancer patients with BM vs stroke. METHODS A descriptive study with prospectively acquired data from a cancer referral center included patients seen at the neuro-oncologic unit from March 2011 to February 2018 with confirmed cancer who had BM or stroke. RESULTS Six hundred and thirteen BM patients were compared with 268 with stroke and cancer. Demographic factors, cancer type, risk factors, clinical presentation, and outcome are presented. Median overall survival in months for those with any stroke was 15 (95%confidence interval [CI] 8.6-21.4)-5 (95%CI 0.12.4) for hemorrhagic stroke and 22 (95%CI 13.4-30.6) in the ischemic group-and for those with BM 12 (95%CI 10.4-13.6). Hemorrhagic stroke commonly found in stroke patients as well as focal motor weakness, aphasia, and altered mental status. BM was more common in breast and lung cancer with headache, visual complaint, and/or vertigo. CONCLUSION Survival in cancer patients with BM is not that different than those with stroke, but clinical presentation and risk factors were found different.
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Affiliation(s)
- Bernardo Cacho-Díaz
- Neuro-oncology Unit, Research Unit, Instituto Nacional de Cancerología, Mexico City, Mexico.
| | - Héctor Spínola-Maroño
- Neuro-oncology Unit, Research Unit, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Laura G Mendoza-Olivas
- Neuro-oncology Unit, Research Unit, Instituto Nacional de Cancerología, Mexico City, Mexico
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Ito S, Kikuchi K, Ueda A, Nagao R, Maeda T, Murate K, Shima S, Mizutani Y, Niimi Y, Mutoh T. Changes in Serial D-Dimer Levels Predict the Prognoses of Trousseau's Syndrome Patients. Front Neurol 2018; 9:528. [PMID: 30018592 PMCID: PMC6037767 DOI: 10.3389/fneur.2018.00528] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 06/13/2018] [Indexed: 12/21/2022] Open
Abstract
Background: The development of acute multiple embolic infarctions (AMEI) resulting from cancer is known as Trousseau's syndrome (TS). At present, however, there is no good marker for predicting the prognosis of TS patients. In the present study, we evaluated the use of serial D-dimer levels as a prognostic marker for TS. Methods: This retrospective cohort study included 1,409 consecutive acute ischemic stroke patients. We selected a group of patients with TS showing AMEI (n = 38; TS group) and a group of patients with atrial fibrillation (Af) and AMEI (n = 35; Af group) as controls. Serial D-dimer levels were measured between days 7 and 28 after stroke (sub-acute phase) in 21 patients of the TS group and 24 patients of the Af group. Results: D-dimer levels at onset (acute phase) were significantly higher in the TS group (8.45 ± 1.79 μg/mL, n = 38) compared with the Af group (1.14 ± 0.14 μg/mL, n = 35) (p < 0.0001). In patients for whom serial D-dimer measurements were made, D-dimer levels measured at the sub-acute phase decreased to 0.48 ± 0.12 μg/mL (n = 24) in the Af group, but remained elevated in the TS group during the sub-acute phase (11.20 ± 2.77 μg/mL, n = 21) (p < 0.0001). In all TS patients in whom serial D-dimer measurements were made, D-dimer levels in 17 patients who died within 500 days (13.31 ± 3.23 μg/mL) were significantly higher than those of the four surviving patients (2.23 ± 0.38 μg/mL) (cut-off D-dimer level = 3.0 μg/mL) during this period. Moreover, serial D-dimer levels of 10 patients who died within 90 days (17.78 ± 4.60 μg/mL) were significantly higher than those of the 11 patients who survived up to 90 days (5.21 ± 2.12 μg/mL) (p < 0.05). Conclusions: Serial D-dimer levels may be a good biomarker for TS as well as a useful predictor of the prognosis of TS patients.
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Affiliation(s)
- Shinji Ito
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Koichi Kikuchi
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Akihiro Ueda
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Ryunosuke Nagao
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Toshiki Maeda
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Kenichiro Murate
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Sayuri Shima
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Yasuaki Mizutani
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Yoshiki Niimi
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Tatsuro Mutoh
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
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Chen W, He Y, Su Y. Multifocal cerebral infarction as the first manifestation of occult malignancy: Case series of trousseau's syndrome and literature review. Brain Circ 2018; 4:65-72. [PMID: 30276339 PMCID: PMC6126242 DOI: 10.4103/bc.bc_1_18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 04/22/2018] [Accepted: 05/09/2018] [Indexed: 12/21/2022] Open
Abstract
Ischemic stroke as an initial presentation of malignancy is extremely rare and the underlying etiology is often ignored. The aim of this study is to outline the clues to occult malignancy in patients presenting with cerebral infarction initially. The clinical characteristics of total 19 patients with Trousseau's Syndrome presenting with cerebral infarction initially were analyzed. Among those patients, no conventional vascular risk factors were detected in 68% (13/19) of patients, and infarction occurring in multiple vascular distributions was found in 84% (16/19). Blood test showed thrombophilia in 79% (15/19) of patients with significantly elevated D-dimer, disseminated intravascular coagulopathy (DIC) in 59% (11/19), and elevated levels of tumor makers in 47% (9/19). The prognosis of the 19 patients was poor, with 68% (13/19) of patients undergoing a relapse of stroke in short interval, and 84% (16/19) being reportedly to die in 6 months. In patients, who developed unexplained recurrent brain infarction involving multiple arterial territory, with laboratory evidence suggesting hypercoagulability (higher level of D-dimer, or DIC), Trousseau's Syndrome should be considered, and investigation for an occult malignancy was required.
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Affiliation(s)
- Weibi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yanbo He
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurology, The Beijing Moslem People Hospital, Beijing, China
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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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: 150] [Impact Index Per Article: 25.0] [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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Severe Fatal Systemic Embolism Due to Non-Bacterial Thrombotic Endocarditis as the Initial Manifestation of Gastric Adenocarcinoma: Case Report. ACTA ACUST UNITED AC 2018; 4:68-73. [PMID: 30581998 PMCID: PMC6294991 DOI: 10.2478/jccm-2018-0008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 02/15/2018] [Indexed: 11/20/2022]
Abstract
Introduction Nonbacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, is a rare, underdiagnosed complication of cancer, in the context of a hypercoagulable state. NBTE represents a serious complication due to the high risk of embolisation from the sterile cardiac vegetations. If these are not properly diagnosed and treated, infarctions in multiple arterial territories may occur. Case presentation The case of a 47-year-old male is described. The patient was diagnosed with a gastric adenocarcinoma, in which the first clinical manifestation was NBTE. Subsequently, a hypercoagulability syndrome was associated with multi-organ infarctions, including stroke and eventually resulted in a fatal outcome. Conclusions NBTE must be considered in patients with multiple arterial infarcts with no cardiovascular risk factors, in the absence of an infectious syndrome and negative blood cultures. Cancer screening must be performed to detect the cause of the prothrombotic state.
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Bodenant M, Leys D. Infarti cerebrali del soggetto giovane. Neurologia 2018. [DOI: 10.1016/s1634-7072(18)41288-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Yorita K, Tsuji K, Takano Y, Kuroda N, Sakamoto K, Arii K, Yoshimoto Y, Nakatani K, Ito S. Acantholytic squamous cell carcinoma of the lung with marked lymphogenous metastases and high titers of myeloperoxidase-antineutrophil cytoplasmic antibodies: a case report. BMC Cancer 2018; 18:300. [PMID: 29548309 PMCID: PMC5857100 DOI: 10.1186/s12885-018-4218-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 03/13/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Acantholytic squamous cell carcinoma (ASQCC), histologically characterized by intercellular bridge loosening, is recognized as a rare variant of squamous cell carcinoma (SQCC). ASQCC may demonstrate a worse prognosis than conventional SQCC. Pulmonary ASQCC is particularly rare; its biological behavior and prognostic data have not been reported. CASE PRESENTATION We report the clinical and autopsy findings of a 71-year-old Japanese man with pulmonary ASQCC. Pulmonary lesions, suggestive of idiopathic interstitial pneumonia, were radiologically observed 3 and 6 years prior to the patient's most recent hospitalization; however, the patient did not undergo further medical examinations. Upon being discovered unconscious, the patient was admitted to our hospital. Dehydration and lower limb muscle weakness were noted, as were laboratory findings of coagulation abnormalities and renal dysfunction. Computed tomography helped confirm a 21-mm peripheral nodule in the upper left lobe of the lung, with associated swollen lymph nodes in the bilateral hilar, mediastinal, and para-aortic regions. Brain and spinal lesions, suggestive of neurological disturbances, were not found. Small cell lung carcinoma was suspected, upon admission, but high serum levels of squamous cell carcinoma antigen and cytokeratin-19 fragments were present. Therefore, advanced lung cancer, possibly SQCC, was diagnosed. The patient was treated with best supportive therapy, and died one month after admission. Hypercalcemia and high serum levels of parathyroid hormone-related protein (PTHrP) and myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) titers were observed. Progressive renal insufficiency was absent due to improved renal function subsequent to hydration. An autopsy helped confirm the left lung tumor as an ASQCC associated with pulmonary lymphangitic carcinomatosis and multiple metastases in the lungs and lymph nodes. Skin lesions suggesting malignant tumors were absent. The metastatic lesions consisted largely of acantholytic tumor cells, and the lungs showed usual interstitial pneumonia pattern; vasculitis was absent. CONCLUSIONS This is the first reported case of pulmonary ASQCC resulting in an aggressive clinical course, with marked lymphogenous metastases and PTHrP-associated hypercalcemia. The high serum MPO-ANCA titers were clinicopathologically insignificant, but may have been related to the pulmonary interstitial lesion. Pulmonary ASQCC represents a highly malignant subset of lung cancer.
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Affiliation(s)
- Kenji Yorita
- Department of Diagnostic Pathology, Japanese Red Cross Kochi Hospital, 2-13-51, Shinhonmachi, Kochi-city, Kochi, 780-8562 Japan
| | - Kazuya Tsuji
- Department of Internal Medicine, Japanese Red Cross Kochi Hospital, 2-13-51, Shinhonmachi, Kochi-city, Kochi, 780-8562 Japan
| | - Yoko Takano
- Department of Internal Medicine, Japanese Red Cross Kochi Hospital, 2-13-51, Shinhonmachi, Kochi-city, Kochi, 780-8562 Japan
| | - Naoto Kuroda
- Department of Diagnostic Pathology, Japanese Red Cross Kochi Hospital, 2-13-51, Shinhonmachi, Kochi-city, Kochi, 780-8562 Japan
| | - Kei Sakamoto
- Department of Internal Medicine, Japanese Red Cross Kochi Hospital, 2-13-51, Shinhonmachi, Kochi-city, Kochi, 780-8562 Japan
| | - Kaoru Arii
- Department of Internal Medicine, Japanese Red Cross Kochi Hospital, 2-13-51, Shinhonmachi, Kochi-city, Kochi, 780-8562 Japan
| | - Yukio Yoshimoto
- Department of Internal Medicine, Japanese Red Cross Kochi Hospital, 2-13-51, Shinhonmachi, Kochi-city, Kochi, 780-8562 Japan
| | - Kimiko Nakatani
- Department of Radiology, Japanese Red Cross Kochi Hospital, 2-13-51, Shinhonmachi, Kochi-city, Kochi, 780-8562 Japan
| | - Satoshi Ito
- Department of Radiology, Japanese Red Cross Kochi Hospital, 2-13-51, Shinhonmachi, Kochi-city, Kochi, 780-8562 Japan
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Schoellhammer L, Owen-Falkenberg A, Gottschalksen B, Shahidi S. Midt-Term Results after Fast-Track Prophylactic Carotid Surgery Program: The Risk of Overlooking Occult Cancer. J Stroke Cerebrovasc Dis 2018; 27:531-538. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/24/2017] [Indexed: 10/18/2022] Open
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Cacho-Díaz B, Lorenzana-Mendoza NA, Spínola-Maroño H, Reyes-Soto G, Cantú-Brito C. Comorbidities, Clinical Features, and Prognostic Implications of Cancer Patients with Cerebrovascular Disease. J Stroke Cerebrovasc Dis 2018; 27:365-371. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/01/2017] [Accepted: 09/07/2017] [Indexed: 12/12/2022] Open
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Wang L, Xu Y, Tuo M, Zhang L, Zhang H, Wang J. Recurrent stroke in a patient of lung cancer without pulmonary mass: A case report. Medicine (Baltimore) 2018; 97:e9815. [PMID: 29384885 PMCID: PMC5805457 DOI: 10.1097/md.0000000000009815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Repeated occurring stroke in short intervals with hypercoagulability is unusual so in such cases the conventional vascular risk factors might not be the causes of stroke. PATIENT CONCERNS We have presented a case of 60-year-old male presenting with recurrent stroke due to thrombophilia. DIAGNOSES Lung cancer was detected by superficial lymph nodes ultrasound and further pathological examination. INTERVENTIONS The patient suffered a recurrent stroke and he had persistently high level of D-dimer which suggested the diagnosis of thrombophilia, thus, he was treated with low-molecular-weight heparin. Unfortunately, the treatment was not effective for the patient and he died before any other treatments could be administered. OUTCOMES Despite anticoagulant therapy, the patient suffered multiple episodes of stroke and ultimately died. LESSONS This case of recurrent stroke with coagulation disorders without evidence of cancer in imaging and blood test is rare. So in a stroke patient, we should consider malignancy or metastasis as a differential diagnosis as it may be the first manifestation of active cancer elsewhere.
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Predictors of unknown cancer in patients with ischemic stroke. J Neurooncol 2018; 137:551-557. [DOI: 10.1007/s11060-017-2741-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 12/29/2017] [Indexed: 02/06/2023]
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49
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Rare Presentation of Pancreatic Cancer: A Case Report. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2017. [DOI: 10.5812/ijcm.9052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
BACKGROUND The risk of arterial thromboembolism in patients with cancer is incompletely understood. OBJECTIVES The authors aimed to better define this epidemiological relationship, including the effects of cancer stage. METHODS Using the Surveillance Epidemiology and End Results-Medicare linked database, the authors identified patients with a new primary diagnosis of breast, lung, prostate, colorectal, bladder, pancreatic, or gastric cancer or non-Hodgkin lymphoma from 2002 to 2011. They were individually matched by demographics and comorbidities to a Medicare enrollee without cancer, and each pair was followed through 2012. Validated diagnosis codes were used to identify arterial thromboembolism, defined as myocardial infarction or ischemic stroke. Cumulative incidence rates were calculated using competing risk survival statistics. Cox hazards analysis was used to compare rates between groups at discrete time points. RESULTS The authors identified 279,719 pairs of patients with cancer and matched control patients. The 6-month cumulative incidence of arterial thromboembolism was 4.7% (95% confidence interval [CI]: 4.6% to 4.8%) in patients with cancer compared with 2.2% (95% CI: 2.1% to 2.2%) in control patients (hazard ratio [HR]: 2.2; 95% CI: 2.1 to 2.3). The 6-month cumulative incidence of myocardial infarction was 2.0% (95% CI: 1.9% to 2.0%) in patients with cancer compared with 0.7% (95% CI: 0.6% to 0.7%) in control patients (HR: 2.9; 95% CI: 2.8 to 3.1). The 6-month cumulative incidence of ischemic stroke was 3.0% (95% CI: 2.9% to 3.1%) in patients with cancer compared with 1.6% (95% CI: 1.6% to 1.7%) in control patients (HR: 1.9; 95% CI: 1.8 to 2.0). Excess risk varied by cancer type (greatest for lung), correlated with cancer stage, and generally had resolved by 1 year. CONCLUSIONS Patients with incident cancer face a substantially increased short-term risk of arterial thromboembolism.
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