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Kassubek R, Winter MAGR, Dreyhaupt J, Laible M, Kassubek J, Ludolph AC, Lewerenz J. Development of an algorithm for identifying paraneoplastic ischemic stroke in association with lung, pancreatic, and colorectal cancer. Ther Adv Neurol Disord 2024; 17:17562864241239123. [PMID: 38596402 PMCID: PMC11003337 DOI: 10.1177/17562864241239123] [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: 07/27/2023] [Accepted: 02/19/2024] [Indexed: 04/11/2024] Open
Abstract
Background Paraneoplastic ischemic stroke has a poor prognosis. We have recently reported an algorithm based on the number of ischemic territories, C-reactive protein (CRP), lactate dehydrogenase (LDH), and granulocytosis to predict the underlying active cancer in a case-control setting. However, co-occurrence of cancer and stroke might also be merely incidental. Objective To detect cancer-associated ischemic stroke in a large, unselected cohort of consecutive stroke patients by detailed analysis of ischemic stroke associated with specific cancer subtypes and comparison to patients with bacterial endocarditis. Methods Retrospective single-center cohort study of consecutive 1612 ischemic strokes with magnetic resonance imaging, CRP, LDH, and relative granulocytosis data was performed, including identification of active cancers, history of now inactive cancers, and the diagnosis of endocarditis. The previously developed algorithm to detect paraneoplastic cancer was applied. Tumor types associated with paraneoplastic stroke were used to optimize the diagnostic algorithm. Results Ischemic strokes associated with active cancer, but also endocarditis, were associated with more ischemic territories as well as higher CRP and LDH levels. Our previous algorithm identified active cancer-associated strokes with a specificity of 83% and sensitivity of 52%. Ischemic strokes associated with lung, pancreatic, and colorectal (LPC) cancers but not with breast and prostate cancers showed more frequent and prominent characteristics of paraneoplastic stroke. A multiple logistic regression model optimized to identify LPC cancers detected active cancer with a sensitivity of 77.8% and specificity of 81.4%. The positive predictive value (PPV) for all active cancers was 13.1%. Conclusion Standard clinical examinations can be employed to identify suspect paraneoplastic stroke with an adequate sensitivity, specificity, and PPV when it is considered that the association of ischemic stroke with breast and prostate cancers in the stroke-prone elderly population might be largely incidental.
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Affiliation(s)
- Rebecca Kassubek
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany
| | | | - Jens Dreyhaupt
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Mona Laible
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Jan Kassubek
- Department of Neurology, University of Ulm, Ulm, Germany
- German Center for Neurodegenerative Diseases (DZNE) Ulm, Ulm, Germany
| | - Albert C. Ludolph
- Department of Neurology, University of Ulm, Ulm, Germany
- German Center for Neurodegenerative Diseases (DZNE) Ulm, Ulm, Germany
| | - Jan Lewerenz
- Department of Neurology, University of Ulm, Ulm, Germany
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Costamagna G, Hottinger AF, Milionis H, Salerno A, Strambo D, Livio F, Navi BB, Michel P. Acute ischaemic stroke in active cancer versus non-cancer patients: stroke characteristics, mechanisms and clinical outcomes. Eur J Neurol 2024; 31:e16200. [PMID: 38235924 DOI: 10.1111/ene.16200] [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: 08/18/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND PURPOSE Demographics, clinical characteristics, stroke mechanisms and long-term outcomes were compared between acute ischaemic stroke (AIS) patients with active cancer (AC) versus non-cancer patients. METHODS Using data from 2003 to 2021 in the Acute STroke Registry and Analysis of Lausanne, a retrospective cohort study was performed comparing patients with AC, including previously known and newly diagnosed cancers, with non-cancer patients. Patients with inactive cancer were excluded. Outcomes were the modified Rankin Scale (mRS) score at 3 months, death and cerebrovascular recurrences at 12 months before and after propensity score matching. RESULTS Amongst 6686 patients with AIS, 1065 (15.9%) had a history of cancer. After excluding 700 (10.4%) patients with inactive cancer, there were 365 (5.5%) patients with AC and 5621 (84%) non-cancer AIS patients. Amongst AC patients, 154 (42.2%) strokes were classified as cancer related. In multivariable analysis, patients with AC were older (adjusted odds ratio [aOR] 1.02, 95% confidence interval [CI] 1.00-1.03), had fewer vascular risk factors and were 48% less likely to receive reperfusion therapies (aOR 0.52, 95% CI 0.35-0.76). Three-month mRS scores were not different in AC patients (aOR 2.18, 95% CI 0.96-5.00). At 12 months, death (adjusted hazard ratio 1.91, 95% CI 1.50-2.43) and risk of cerebrovascular recurrence (sub-distribution hazard ratio 1.68, 95% CI 1.22-2.31) before and after propensity score matching were higher in AC patients. CONCLUSIONS In a large institutional registry spanning nearly two decades, AIS patients with AC had less past cerebrovascular disease but a higher 1-year risk of subsequent death and cerebrovascular recurrence compared to non-cancer patients. Antithrombotic medications at discharge may reduce this risk in AC patients.
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Affiliation(s)
- Gianluca Costamagna
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Dino Ferrari Centre, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Milan, Italy
| | - Andreas F Hottinger
- Lundin and Family Brain Tumor Research Center, Services of Neurology and Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haralampos Milionis
- First Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Francoise Livio
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Babak B Navi
- Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York City, New York, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Costamagna G, Navi BB, Beyeler M, Hottinger AF, Alberio L, Michel P. Ischemic Stroke in Cancer: Mechanisms, Biomarkers, and Implications for Treatment. Semin Thromb Hemost 2024; 50:342-359. [PMID: 37506734 DOI: 10.1055/s-0043-1771270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Ischemic stroke is an important cause of morbidity and mortality in cancer patients. The underlying mechanisms linking cancer and stroke are not completely understood. Long-standing and more recent evidence suggests that cancer-associated prothrombotic states, along with treatment-related vascular toxicity, such as with chemotherapy and immunotherapy, contribute to an increased risk of ischemic stroke in cancer patients. Novel biomarkers, including coagulation, platelet and endothelial markers, cell-free DNA, and extracellular vesicles are being investigated for their potential to improve risk stratification and patient selection for clinical trials and to help guide personalized antithrombotic strategies. Treatment of cancer-related stroke poses unique challenges, including the need to balance the risk of recurrent stroke and other thromboembolic events with that of bleeding associated with antithrombotic therapy. In addition, how and when to restart cancer treatment after stroke remains unclear. In this review, we summarize current knowledge on the mechanisms underlying ischemic stroke in cancer, propose an etiological classification system unique to cancer-related stroke to help guide patient characterization, provide an overview of promising biomarkers and their clinical utility, and discuss the current state of evidence-based management strategies for cancer-related stroke. Ultimately, a personalized approach to stroke prevention and treatment is required in cancer patients, considering both the underlying cancer biology and the individual patient's risk profile.
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Affiliation(s)
- Gianluca Costamagna
- Stroke Unit, Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas F Hottinger
- Services of Neurology and Oncology, Lundin Family Brain Tumor Research Center, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Hematology Central Laboratory, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Stroke Center, Neurology Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Fang J, Wu J, Hong G, Zheng L, Yu L, Liu X, Lin P, Yu Z, Chen D, Lin Q, Jing C, Zhang Q, Wang C, Zhao J, Yuan X, Wu C, Zhang Z, Guo M, Zhang J, Zheng J, Lei A, Zhang T, Lan Q, Kong L, Wang X, Wang Z, Ma Q. Cancer screening in hospitalized ischemic stroke patients: a multicenter study focused on multiparametric analysis to improve management of occult cancers. EPMA J 2024; 15:53-66. [PMID: 38463627 PMCID: PMC10923752 DOI: 10.1007/s13167-024-00354-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/02/2024] [Indexed: 03/12/2024]
Abstract
Background/aims The reciprocal promotion of cancer and stroke occurs due to changes in shared risk factors, such as metabolic pathways and molecular targets, creating a "vicious cycle." Cancer plays a direct or indirect role in the pathogenesis of ischemic stroke (IS), along with the reactive medical approach used in the treatment and clinical management of IS patients, resulting in clinical challenges associated with occult cancer in these patients. The lack of reliable and simple tools hinders the effectiveness of the predictive, preventive, and personalized medicine (PPPM/3PM) approach. Therefore, we conducted a multicenter study that focused on multiparametric analysis to facilitate early diagnosis of occult cancer and personalized treatment for stroke associated with cancer. Methods Admission routine clinical examination indicators of IS patients were retrospectively collated from the electronic medical records. The training dataset comprised 136 IS patients with concurrent cancer, matched at a 1:1 ratio with a control group. The risk of occult cancer in IS patients was assessed through logistic regression and five alternative machine-learning models. Subsequently, select the model with the highest predictive efficacy to create a nomogram, which is a quantitative tool for predicting diagnosis in clinical practice. Internal validation employed a ten-fold cross-validation, while external validation involved 239 IS patients from six centers. Validation encompassed receiver operating characteristic (ROC) curves, calibration curves, decision curve analysis (DCA), and comparison with models from prior research. Results The ultimate prediction model was based on logistic regression and incorporated the following variables: regions of ischemic lesions, multiple vascular territories, hypertension, D-dimer, fibrinogen (FIB), and hemoglobin (Hb). The area under the ROC curve (AUC) for the nomogram was 0.871 in the training dataset and 0.834 in the external test dataset. Both calibration curves and DCA underscored the nomogram's strong performance. Conclusions The nomogram enables early occult cancer diagnosis in hospitalized IS patients and helps to accurately identify the cause of IS, while the promotion of IS stratification makes personalized treatment feasible. The online nomogram based on routine clinical examination indicators of IS patients offered a cost-effective platform for secondary care in the framework of PPPM. Supplementary Information The online version contains supplementary material available at 10.1007/s13167-024-00354-8.
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Affiliation(s)
- Jie Fang
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
- School of Medicine, Xiamen University, Xiamen, China
| | - Jielong Wu
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- School of Medicine, Xiamen University, Xiamen, China
- National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen, China
| | - Ganji Hong
- Cerebrovascular Interventional Department, Zhangzhou Hospital of Fujian Province, Zhangzhou, China
| | - Liangcheng Zheng
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Lu Yu
- Department of Neurology, Changxing People’s Hospital, Huzhou, China
| | - Xiuping Liu
- Department of Neurology, The Jilin Center Hospital, Jilin, China
| | - Pan Lin
- Department of Neurology, The Second Hospital of Longyan City, Longyan, China
| | - Zhenzhen Yu
- Department of Neurology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Dan Chen
- Department of Neurology, Xiamen Haicang Hospital, Xiamen, China
| | - Qing Lin
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Chuya Jing
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Qiuhong Zhang
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Chen Wang
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Jiedong Zhao
- School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Xiaodong Yuan
- Department of Gynecology of Xiamen Maternal and Child Health Care Hospital, Xiamen, China
| | - Chunfang Wu
- Department of Neurology, Huaihe Hospital, Henan University, Huaihe, China
| | - Zhaojie Zhang
- Department of Neurology, Kaifeng Hospital of Traditional Chinese Medicine, Kaifeng, China
| | - Mingwei Guo
- Department of Neurology, First Affiliated Hospital of Gannan Medical University, Gannan, China
| | - Junde Zhang
- Department of Neurology, First Affiliated Hospital of Gannan Medical University, Gannan, China
| | - Jingjing Zheng
- Department of Neurology, Ningde Municipal Hospital of Ningde Normal University, Ningde, China
| | - Aidi Lei
- Department of Neurology, The Fifth Hospital of Xiamen, Xiamen, China
| | - Tengkun Zhang
- Department of Neurology, The Fifth Hospital of Xiamen, Xiamen, China
| | - Quan Lan
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | | | - Xinrui Wang
- NHC Key Laboratory of Technical Evaluation of Fertility Regulation for Non-Human Primate (Fujian Maternity and Child Health Hospital), No. 19 Jinjishan Road, Jin’an District, Fuzhou, 350013 China
- Medical Research Center, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Maternityand Child Health Hospital, Fujian Medical University, Fuzhou, China
| | - Zhanxiang Wang
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
- School of Medicine, Xiamen University, Xiamen, China
- National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen, China
- Department of Neurosurgery and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
| | - Qilin Ma
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
- School of Medicine, Xiamen University, Xiamen, China
- National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen, China
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Chen W, Li Y, Wang W, Xue Y, Qian J, Liu W, Hu X. Prognostic value of coagulation markers in patients with colorectal caner: A prospective study. Health Sci Rep 2024; 7:e1553. [PMID: 38304067 PMCID: PMC10831132 DOI: 10.1002/hsr2.1553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 07/17/2023] [Accepted: 08/30/2023] [Indexed: 02/03/2024] Open
Abstract
Background and Aims The occurrence, growth, and metastasis of colorectal cancer (CRC) are connected to the hypercoagulable state of blood (CRC). This study aimed to identify significant coagulation factors to predict metastasis and prognosis of CRC. Methods Thrombomodulin (TM), thrombin-antithrombin complex (TAT), α2-plasmininhibitor-plasmin complex (PIC), and tissue plasminogen activator-inhibitor complex (t-PAIC) were detected by chemiluminescence immunoassay using Sysmex HISCL5000 automated analyzers. The Sysmex CS 5100 automatic blood coagulation analyzer was used to detect d-dimer (DD), fibrin degradation product (FDP), prothrombin time (PT), thrombin time (TT), international normalized ratio (INR), fibrinogen (Fbg), and activated partial thromboplastin time (APTT). Area under the curve (AUC) and the receiver operating characteristic curve (ROC) were used to assess the diagnostic efficacy of markers. Kaplan-Meier analysis was used to calculate survival probabilities. Independent prognostic factors and the nomogram were developed using single-factor and multifactor cox regression analysis model. Results The following indicators (TM, TAT, PIC, t-PAIC, DD, FDP, PT, INR, APTT, and Fbg) were markedly higher in CRC patients than in healthy controls, and they were higher in the metastasis (M) group than in the nonmetastasis (NM) group. The combination "TAT + PIC + DD + FDP + Fbg" can distinguish M from NM with exceptional sensitivity and specificity. Patients with CRC who had high levels of TAT, PIC, DD, FDP, Fbg, TM, tPAIC, PT, and INR had significantly shorter survival. Conclusion The prognosis of CRC patients can be predicted by coagulation indicators. The independent predictive variables for overall survival were found to be TM and DD. To forecast CRC patient survival, a nomogram was created.
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Affiliation(s)
- Wenxin Chen
- Department of Laboratory Medicine, Longhua HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Yueying Li
- Department of Laboratory Medicine, Longhua HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
- Department of Laboratory Medicine and Central Laboratory, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Weifeng Wang
- Department of Laboratory Medicine, Longhua HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
- Department of Laboratory Medicine and Central Laboratory, Shanghai Tenth People's HospitalTongji University School of MedicineShanghaiChina
| | - Yingjun Xue
- Department of Laboratory Medicine, Longhua HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Jianxin Qian
- Department of OncologyLonghua Hospital Affiliated to Shanghai University of Traditional Chinese MedicineShanghaiChina
| | - Weiwei Liu
- Department of Laboratory Medicine, Longhua HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Xiaobo Hu
- General OfficeShanghai Center for Clinical LaboratoryShanghaiChina
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Magami S, Yoshida K, Nakao Y, Oishi H, Yamamoto T. A Single-Center Experience of Mechanical Thrombectomy for Cancer-Associated Ischemic Stroke. JOURNAL OF NEUROENDOVASCULAR THERAPY 2024; 18:37-46. [PMID: 38384394 PMCID: PMC10878738 DOI: 10.5797/jnet.oa.2023-0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/20/2023] [Indexed: 02/23/2024]
Abstract
Objectives Cancer-associated ischemic stroke tends to extend over multiple vascular territories and develops under poor general conditions. Owing to the rarity of such cases and poor prognoses, no comprehensive studies on mechanical thrombectomy for cancer-associated ischemic stroke have been reported in Japan. The present study investigated the radiological and clinical characteristics of mechanical thrombectomy in patients with cancer-associated ischemic stroke at our institution. Methods We retrospectively reviewed 108 patients who underwent mechanical thrombectomy for large cerebral artery occlusion between January 1, 2021, and October 31, 2022, at our institution. The characteristics of mechanical thrombectomy in the cancer-associated ischemic stroke group were compared with those in the control group. Results Of the 108 patients (112 procedures), seven patients (eight procedures) with clinically diagnosed cancer-associated ischemic stroke underwent mechanical thrombectomy. Of the eight procedures, six were performed during hospitalization. In contrast, only 10 of 104 procedures were performed in the control group. The in-hospital onset rate was higher in the cancer-associated ischemic stroke group (75.0%) compared to that in the controls (9.6%); p <0.001. The puncture-to-reperfusion time was significantly longer in the cancer-associated ischemic stroke group in comparison to that in the controls with a median interquartile range of 69 minutes (60.0-82.0 minutes) and 59.5 minutes (44.5-69.3 minutes), respectively (p <0.01). However, the rates of successful recanalization defined as thrombolysis in cerebral infarction ≥2b were not significantly different between the cancer-associated ischemic stroke group and controls with values of 62.5% and 79.8%, respectively (p = 0.250). Of the eight cases in the cancer-associated ischemic stroke group, only one (12.5%) had a good outcome on a modified Rankin Scale score of 0 to 2 at discharge, in contrast to 23 of the 104 (23.1%) cases in the controls (p = 0.523). Histopathological examination of six retrieved thrombi in the cancer-associated stroke group using hematoxylin and eosin staining revealed that only one case showed an erythrocyte-dominant thrombus while five displayed a fibrinoplatelet-dominant component. Conversely, 65 of 92 retrieved thrombi in the control group were erythrocyte dominant. Cancer was pathologically diagnosed in four of seven patients, all of which were adenocarcinomas. Conclusion Cancer-associated ischemic stroke tends to occur during hospitalization. Coagulation disorders associated with cancer, especially adenocarcinoma, may be related to the formation of thrombi with fibrinoplatelet-dominant components, leading to ischemic stroke. The procedural time for mechanical thrombectomy in cancer-associated ischemic stroke tends to be longer.
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Affiliation(s)
- Shunsuke Magami
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Kouhei Yoshida
- Department of Neurosurgery, Juntendo University, Tokyo, Japan
| | - Yasuaki Nakao
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Hidenori Oishi
- Department of Neurosurgery, Juntendo University, Tokyo, Japan
- Department of Neuroendovascular Therapy, Juntendo University, Tokyo, Japan
| | - Takuji Yamamoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
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Yan H, Sasaki T, Gon Y, Nishiyama K, Kanki H, Mochizuki H. Driver gene KRAS aggravates cancer-associated stroke outcomes. Thromb Res 2024; 233:55-68. [PMID: 38029547 DOI: 10.1016/j.thromres.2023.11.015] [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: 06/01/2023] [Revised: 11/04/2023] [Accepted: 11/14/2023] [Indexed: 12/01/2023]
Abstract
The incidence of cancer-associated stroke has increased with the prolonged survival times of cancer patients. Recent genetic studies have led to progress in cancer therapeutics, but relationships between oncogenic mutations and stroke remain elusive. Here, we focused on the driver gene KRAS, which is the predominant RAS isoform mutated in multiple cancer types, in cancer associated stroke study. KRASG13D/- and parental human colorectal carcinoma HCT116 cells were inoculated into mice that were then subjected to a photochemically-induced thrombosis model to establish ischemic stroke. We found that cancer inoculation exacerbated neurological deficits after stroke. Moreover, mice inoculated with KRASG13D/- cells showed worse neurological deficits after stroke compared with mice inoculated with parental cells. Stroke promoted tumor growth, and the KRASG13D/- allele enhanced this growth. Brain RNA sequencing analysis and serum ELISA showed that chemokines and cytokines mediating pro-inflammatory responses were upregulated in mice inoculated with KRASG13D/- cells compared with those inoculated with parental cells. STAT3 phosphorylation was promoted following ischemic stroke in the KRASG13D/- group compared with in the parental group, and STAT3 inhibition significantly ameliorated stroke outcomes by mitigating microglia/macrophage polarization. Finally, we compared the prognosis and mortality of colorectal cancer patients with or without stroke onset between 1 January 2007 and 31 December 2020 using a hospital-based cancer registry and found that colorectal cancer patients with stroke onset within 3 months after cancer diagnosis had a worse prognosis. Our work suggests an interplay between KRAS and ischemic stroke that may offer insight into future treatments for cancer-associated stroke.
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Affiliation(s)
- Haomin Yan
- Department of Neurology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka 565-0871, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka 565-0871, Japan; Department of Neurotherapeutics, Graduate School of Medicine, Osaka University, Osaka, Japan.
| | - Yasufumi Gon
- Department of Neurology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka 565-0871, Japan
| | - Kumiko Nishiyama
- Department of Neurology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka 565-0871, Japan
| | - Hideaki Kanki
- Department of Neurology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka 565-0871, Japan
| | - Hideki Mochizuki
- Department of Neurology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka 565-0871, Japan
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Ogawa S, Miyawaki S, Imai H, Hongo H, Umekawa M, Kiyofuji S, Ishigami D, Sakai Y, Torazawa S, Hirano Y, Koizumi S, Saito N. Cerebrovascular Events During Treatment for Systemic Malignant Tumors in Patients with Moyamoya Disease. World Neurosurg 2023; 179:e314-e320. [PMID: 37634665 DOI: 10.1016/j.wneu.2023.08.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 08/20/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE With the increasing incidence of malignancies, the importance of cancer-associated stroke is emphasized. Although moyamoya disease is a leading cause of stroke, no reports have documented cancer-associated stroke in patients with this condition. We aimed to investigate cerebrovascular events during malignancy treatments in patients with moyamoya disease. METHODS A total of 405 patients with moyamoya disease who visited our hospital between January 2000 and March 2022 were retrospectively examined. We evaluated the management of moyamoya disease, presence of the ring finger protein 213 p.Arg4810Lys variant, treatments for malignant tumors, presence of cerebrovascular events during treatment, and follow-up periods and outcomes. RESULTS Among the 405 patients, 17 patients with moyamoya disease (4.2%) were diagnosed with malignancies. Among patients aged 60 years and over, 7 out of 67 (10.4%) had malignancies. Of the 17 patients, 11 (64.7%) were symptomatic, and 7 (41.2%) had revascularization surgery. 9 patients were treated with oral antiplatelet drugs. There was no significant difference between the groups with and without malignancy regarding the presence of the ring finger protein 213 p.Arg4810Lys variant (80.0% vs. 62.7%, P = 0.33). All patients underwent surgical treatment, and 7 (41.2%) received chemotherapy. One death due to tumor progression was reported. No cerebrovascular event was observed during malignancy treatments and follow-up periods, which had a mean duration of 6 years. CONCLUSIONS In our cohort, malignancy treatments in patients with moyamoya disease were safely conducted without cerebrovascular events. However, it is advisable to avoid hypotension, dehydration, hyperventilation, and long-term discontinuation of antiplatelet drugs during the treatment of malignant tumors.
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Affiliation(s)
- Shotaro Ogawa
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Hideaki Imai
- Department of Neurosurgery, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Hiroki Hongo
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Motoyuki Umekawa
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoshi Kiyofuji
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Daiichiro Ishigami
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yu Sakai
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Seiei Torazawa
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yudai Hirano
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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9
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Kwon JY, Park K, Song JM, Pyeon SY, Lee SH, Chung YS, Lee JM. Risk Factors and Prognosis of Stroke in Gynecologic Cancer Patients. Cancers (Basel) 2023; 15:4895. [PMID: 37835590 PMCID: PMC10572068 DOI: 10.3390/cancers15194895] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/03/2023] [Accepted: 10/08/2023] [Indexed: 10/15/2023] Open
Abstract
Increased life expectancy and cancer prevalence rates expose patients to a higher risk of developing other comorbidities such as stroke. This study aimed to evaluate the risk factors for and prognosis of stroke in patients with gynecological cancers. A single-center retrospective cohort study was conducted on patients with cervical, endometrial, and epithelial ovarian cancers. Patients were classified into three groups based on the period of stroke onset: at least one year before cancer diagnosis, within one year before cancer diagnosis to six months after the last treatment date, and six months after the last treatment date. Among the 644 patients, stroke occurred in 54 (8.4%). In univariate analysis, stroke was significantly associated with overall survival. In contrast, in multivariate analysis, stroke was significantly associated with age and hypertension, but not with overall survival. Age, pulmonary thromboembolism/deep vein thrombosis, histological grade, and tumor stage were significantly associated with overall survival. Therefore, it is important to establish an appropriate examination and treatment plan for patients with gynecologic cancers using a multidisciplinary approach that incorporates the patient's age, medical condition, and tumor characteristics rather than excessively considering the adverse effects of stroke on cancer prognosis.
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Affiliation(s)
- Ji Young Kwon
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea; (J.Y.K.); (K.P.); (J.M.S.); (S.Y.P.); (Y.S.C.)
- Department of Medicine, Graduate School, Kyung Hee University, Seoul 02447, Republic of Korea
| | - Kena Park
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea; (J.Y.K.); (K.P.); (J.M.S.); (S.Y.P.); (Y.S.C.)
- Department of Medicine, Graduate School, Kyung Hee University, Seoul 02447, Republic of Korea
| | - Jeong Min Song
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea; (J.Y.K.); (K.P.); (J.M.S.); (S.Y.P.); (Y.S.C.)
- Department of Medicine, Graduate School, Kyung Hee University, Seoul 02447, Republic of Korea
| | - Seung Yeon Pyeon
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea; (J.Y.K.); (K.P.); (J.M.S.); (S.Y.P.); (Y.S.C.)
| | - Seon Hwa Lee
- Medical Big Data Research Center, Research Institute of Clinical Medicine, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea;
| | - Young Shin Chung
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea; (J.Y.K.); (K.P.); (J.M.S.); (S.Y.P.); (Y.S.C.)
| | - Jong-Min Lee
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea; (J.Y.K.); (K.P.); (J.M.S.); (S.Y.P.); (Y.S.C.)
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10
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Ajabnoor AM, Parisi R, Zghebi SS, Ashcroft DM, Faivre‐Finn C, Morris C, Mamas MA, Kontopantelis E. Common Cancer Types and Risk of Stroke and Bleeding in Patients With Nonvalvular Atrial Fibrillation: A Population-Based Study in England. J Am Heart Assoc 2023; 12:e029423. [PMID: 37750567 PMCID: PMC10727261 DOI: 10.1161/jaha.123.029423] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/08/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND The association between cancer and stroke or bleeding outcomes in atrial fibrillation is unclear. We sought to examine how certain types of cancer influence the balance between stroke and bleeding risk in patients with nonvalvular atrial fibrillation (NVAF). METHODS AND RESULTS We estimated stroke and bleeding risk among adult patients with NVAF and certain types of cancer (breast, prostate, colorectal, lung, and hematological cancer) from 2009 to 2019 based on data from the UK Clinical Practice Research Datalink GOLD and Aurum databases. The control group included patients with NVAF only. Of 177 065 patients with NVAF, 11379 (6.4%) had cancer (1691 breast, 3955 prostate, 1666 colorectal, 2491 hematological, and 1576 lung). Compared with patients without cancer, stroke risk was higher in patients with breast cancer (adjusted hazard ratio [aHR], 1.20 [95% CI, 1.07-1.35) and with prostate cancer (aHR, 1.11 [95% CI, 1.01-1.12) if diagnosed within 6 months before NVAF. The risk of bleeding was increased in subjects with hematological cancer (aHR, 1.55 [95% CI, 1.40-1.71]), lung cancer (aHR, 1.49 [95% CI, 1.25, 1.77]), prostate cancer (aHR, 1.38 [95% CI, 1.28-1.49]), and colorectal cancer (aHR, 1.36 [95% CI, 1.21-1.53]), but not for subjects with breast cancer. The more recent the cancer diagnosis before NVAF diagnosis (within 6 months), the higher the risk of bleeding. CONCLUSIONS Breast and prostate cancer are associated with increased stroke risk, whereas in some cancer types, the risk of bleeding seemed to exceed stroke risk. In these patients, prescribing of oral anticoagulant should be carefully evaluated to balance bleeding and stroke risk.
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Affiliation(s)
- Alyaa M. Ajabnoor
- Department of Pharmacy Practice, Faculty of PharmacyKing Abdulaziz UniversityJeddahSaudi Arabia
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC)University of ManchesterManchesterUnited Kingdom
| | - Rosa Parisi
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC)University of ManchesterManchesterUnited Kingdom
| | - Salwa S. Zghebi
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC)University of ManchesterManchesterUnited Kingdom
| | - Darren M. Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUnited Kingdom
- National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Research Collaboration (PSRC)University of ManchesterManchesterUnited Kingdom
| | - Corinne Faivre‐Finn
- The Christie NHS Foundation Trust and The University of ManchesterManchesterUnited Kingdom
| | - Charlotte Morris
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC)University of ManchesterManchesterUnited Kingdom
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health SciencesKeele UniversityKeeleUnited Kingdom
| | - Evangelos Kontopantelis
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC)University of ManchesterManchesterUnited Kingdom
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11
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Cheng Y, Ning Y, Zhao Y, Cao X, Liu H, Shi T. Association between three-territory sign and prognosis of acute ischemic stroke patients with malignancy. Front Neurol 2023; 14:1265715. [PMID: 37840936 PMCID: PMC10568467 DOI: 10.3389/fneur.2023.1265715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 08/31/2023] [Indexed: 10/17/2023] Open
Abstract
Background Multiple cerebral infarcts are usually secondary to cardiogenic embolism, particularly through atrial fibrillation (AF). The three-territory sign (TTS) is an imaging marker that reflects multiple cerebral lesions involving three vascular territories measured by diffusion-weighted imaging (DWI), and the most common etiology is an underlying malignancy. Recent studies have shown that TTS is six times more frequently observed in acute ischemic stroke (AIS) patients with malignancy than in those with AF-related AIS. However, the relevance of TTS to the prognosis of IS patients with malignancy remains unclear. Methods Over a 5-year period (May 2016 to 31 June 2021), AIS admissions with DWI were identified from the First Affiliated Hospital of Xi'an Jiaotong University. Patients were divided into two groups according to whether they had malignancy or AF, resulting in a total of 80 patients with known malignancy (malignancy group) and 92 patients with AF (AF group). All DWI images were reviewed to determine the territory lesion count. Demographic, clinical, and laboratory data, together with radiographic examination data and modified Rankin Scale (mRS) score within a year, were collected. The main outcome was the association between TTS and the prognosis of AIS patients with malignancy, analyzed by a multivariate logistic regression model. Results A total of 172 patients met the selection criteria, including 17 (21.3%) patients in the malignancy group and 8 (8.7%) patients in the AF group with TTS. Age and sex distributions were similar for AIS patients of malignancy and AF. The TTS was 2.4 times more likely to be observed in AIS patients with malignancy compared to AF-related IS patients. The univariate analysis showed that hypertension (OR = 1.137, 95%CI: 1.002-1.291), D-dimer (OR = 1.328, 95%CI: 1.022-1.726), fibrin degradation product (OR = 1.117, 95%CI: 1.010-1.236), and lactate dehydrogenase (LDH; OR = 1.007, 95%CI: 1.000-1.015) were the risk factors for the high mortality rate. Multivariate analysis showed that TTS was the independent risk factor for mortality in AIS patients with malignancy (adjusted OR: 6.866, 95% CI: 1.371-34.395). Conclusion TTS was more frequently observed in AIS patients with malignancy than AF-related AIS and substantially related to high poor outcome (mRS > 2) in AIS patients with malignancy, indicating diagnostic and prognostic value in malignancy-associated hypercoagulation stroke.
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Affiliation(s)
- Yuying Cheng
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yuye Ning
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Innovation Center for Neurological Disorders and Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yixin Zhao
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Xiangqi Cao
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Hui Liu
- Biobank, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Tao Shi
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
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12
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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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13
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Costamagna G, Hottinger A, Milionis H, Lambrou D, Salerno A, Strambo D, Livio F, Navi BB, Michel P. Clinical and Demographic Characteristics, Mechanisms, and Outcomes in Patients With Acute Ischemic Stroke and Newly Diagnosed or Known Active Cancer. Neurology 2023; 100:e2477-e2489. [PMID: 37094994 PMCID: PMC10264053 DOI: 10.1212/wnl.0000000000207341] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/09/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with a new diagnosis of cancer carry an increased risk of acute ischemic stroke (AIS), and this risk varies depending on age, cancer type, stage, and time from diagnosis. Whether patients with AIS with a new diagnosis of neoplasm represent a distinct subset from those with a previously known active malignancy remains unclear. We aimed to estimate the rate of stroke in patients with newly diagnosed cancer (NC) and previously known active cancer (KC) and to compare the demographic and clinical features, stroke mechanisms, and long-term outcomes between groups. METHODS Using 2003-2021 data from the Acute STroke Registry and Analysis of Lausanne registry, we compared patients with KC with patients with NC (cancer identified during AIS hospitalization or within the following 12 months). Patients with inactive and no history of cancer were excluded. Outcomes were the modified Rankin scale (mRS) score at 3 months and mortality and recurrent stroke at 12 months. We used multivariable regression analyses to compare outcomes between groups while adjusting for important prognostic variables. RESULTS Among 6,686 patients with AIS, 362 (5.4%) had active cancer (AC), including 102 (1.5%) with NC. Gastrointestinal and genitourinary cancers were the most frequent cancer types. Among all patients with AC, 152 (42.5%) AISs were classified as cancer related, with nearly half of these cases attributed to hypercoagulability. In multivariable analysis, patients with NC had less prestroke disability (adjusted odds ratio [aOR] 0.62, 95% CI 0.44-0.86) and fewer prior stroke/transient ischemic attack events (aOR 0.43, 95% CI 0.21-0.88) than patients with KC. Three-month mRS scores were similar between cancer groups (aOR 1.27, 95% CI 0.65-2.49) and were predominantly driven by the presence of newly diagnosed brain metastases (aOR 7.22, 95% CI 1.49-43.17) and metastatic cancer (aOR 2.19, 95% CI 1.22-3.97). At 12 months, mortality risk was higher in patients with NC vs patients with KC (hazard ratio [HR] 2.11, 95% CI 1.38-3.21), while recurrent stroke risk was similar between groups (adjusted HR 1.27, 95% CI 0.67-2.43). DISCUSSION In a comprehensive institutional registry spanning nearly 2 decades, 5.4% of patients with AIS had AC, a quarter of which were diagnosed during or within 12 months after the index stroke hospitalization. Patients with NC had less disability and prior cerebrovascular disease, but a higher 1-year risk of subsequent death than patients with KC.
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Affiliation(s)
- Gianluca Costamagna
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Andreas Hottinger
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Haralampos Milionis
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dimitris Lambrou
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexander Salerno
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Davide Strambo
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Françoise Livio
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Babak Benjamin Navi
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Patrik Michel
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
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14
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Deng Y, Zhou F, Li Q, Guo J, Cai B, Li G, Liu J, Li L, Zheng Q, Chang D. Associations between neutrophil-lymphocyte ratio and monocyte to high-density lipoprotein ratio with left atrial spontaneous echo contrast or thrombus in patients with non-valvular atrial fibrillation. BMC Cardiovasc Disord 2023; 23:234. [PMID: 37142962 PMCID: PMC10157900 DOI: 10.1186/s12872-023-03270-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 04/27/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND The importance of inflammation in thrombosis is increasingly appreciated. Neutrophil-lymphocyte ratio (NLR) and monocyte to high-density lipoprotein ratio (MHR) are important indicators of systemic inflammation. This study aimed to investigate the associations between NLR and MHR with left atrial appendage thrombus (LAAT) and spontaneous echo contrast (SEC) in patients with non-valvular atrial fibrillation. METHODS This retrospective, cross-sectional study enrolled 569 consecutive patients with non-valvular atrial fibrillation. Multivariable logistic regression analysis was used to investigate independent risk factors of LAAT/SEC. Receiver operating characteristic (ROC) curves were used to evaluate the specificity and sensitivity of NLR and MHR in predicting LAAT/SEC. Subgroup and Pearson correlation analyses were used to assess the correlations between NLR and MHR with the CHA2DS2-VASc score. RESULTS Multivariate logistic regression analysis showed that NLR (OR: 1.49; 95%CI: 1.173-1.892) and MHR (OR: 2.951; 95%CI: 1.045-8.336) were independent risk factors for LAAT/SEC. The area under the ROC curve of NLR (0.639) and MHR (0.626) was similar to that of the CHADS2 score (0.660) and CHA2DS2-VASc score (0.637). Subgroup and Pearson correlation analyses showed significant but very weak associations between NLR (r = 0.139, P < 0.05) and MHR (r = 0.095, P < 0.05) with the CHA2DS2-VASc score. CONCLUSION Generally, NLR and MHR are independent risk factors for predicting LAAT/SEC in patients with non-valvular atrial fibrillation.
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Affiliation(s)
- Yingjian Deng
- Department of Cardiology, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Faguang Zhou
- Department of Cardiology, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Qiang Li
- Department of Cardiology, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Jincun Guo
- Department of Cardiology, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Binni Cai
- Department of Cardiology, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Guiyang Li
- Department of Cardiology, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Jianghai Liu
- Department of Cardiology, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Linlin Li
- Department of Cardiology, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Qi Zheng
- Department of Psychology, Xiamen Xianyue Hospital, Xiamen, China.
| | - Dong Chang
- Department of Cardiology, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, Xiamen, China.
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15
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Waseem A, Rashid S, Rashid K, Khan MA, Khan R, Haque R, Seth P, Raza SS. Insight into the transcription factors regulating Ischemic Stroke and Glioma in Response to Shared Stimuli. Semin Cancer Biol 2023; 92:102-127. [PMID: 37054904 DOI: 10.1016/j.semcancer.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/28/2023] [Accepted: 04/09/2023] [Indexed: 04/15/2023]
Abstract
Cerebral ischemic stroke and glioma are the two leading causes of patient mortality globally. Despite physiological variations, 1 in 10 people who have an ischemic stroke go on to develop brain cancer, most notably gliomas. In addition, glioma treatments have also been shown to increase the risk of ischemic strokes. Stroke occurs more frequently in cancer patients than in the general population, according to traditional literature. Unbelievably, these events share multiple pathways, but the precise mechanism underlying their co-occurrence remains unknown. Transcription factors (TFs), the main components of gene expression programmes, finally determine the fate of cells and homeostasis. Both ischemic stroke and glioma exhibit aberrant expression of a large number of TFs, which are strongly linked to the pathophysiology and progression of both diseases. The precise genomic binding locations of TFs and how TF binding ultimately relates to transcriptional regulation remain elusive despite a strong interest in understanding how TFs regulate gene expression in both stroke and glioma. As a result, the importance of continuing efforts to understand TF-mediated gene regulation is highlighted in this review, along with some of the primary shared events in stroke and glioma.
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Affiliation(s)
- Arshi Waseem
- Laboratory for Stem Cell & Restorative Neurology, Department of Biotechnology, Era's Lucknow Medical College and Hospital, Era University, Sarfarazganj, Lucknow-226003, India
| | - Sumaiya Rashid
- Department of Pharmacology & Toxicology, College of Pharmacy, Prince Sattam Bin Abdulaziz University, P.O. Box 173, Al-Kharj 11942, Saudi Arabia
| | - Khalid Rashid
- Department of Cancer Biology, Vontz Center for Molecular Studies, Cincinnati, OH 45267-0521
| | | | - Rehan Khan
- Chemical Biology Unit, Institute of Nano Science and Technology, Knowledge City,Mohali, Punjab 140306, India
| | - Rizwanul Haque
- Department of Biotechnology, Central University of South Bihar, Gaya -824236, India
| | - Pankaj Seth
- Molecular and Cellular Neuroscience, Neurovirology Section, National Brain Research Centre, Manesar, Haryana-122052, India
| | - Syed Shadab Raza
- Laboratory for Stem Cell & Restorative Neurology, Department of Biotechnology, Era's Lucknow Medical College and Hospital, Era University, Sarfarazganj, Lucknow-226003, India; Department of Stem Cell Biology and Regenerative Medicine, Era's Lucknow Medical College Hospital, Era University, Sarfarazganj, Lucknow-226003, India
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16
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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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17
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Puente-Hernandez M, Rivero-de-Aguilar A, Varela-Lema L. Cancer-associated spinal cord infarction: A systematic review and analysis of survival predictors. J Neurol Sci 2023; 446:120580. [PMID: 36764185 DOI: 10.1016/j.jns.2023.120580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/09/2022] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE The association between spinal cord infarction (SCI) and cancer is an infrequent condition but requires an accurate diagnosis to establish the appropriate treatment. Clinical features and prognosis of cancer-associated SCI have never been assessed. The aim of this systematic review is to describe the characteristics and outcomes of patients with cancer-associated SCI. Illustratively, a case of ovarian cancer-related SCI is presented. MATERIAL AND METHODS Two authors independently analysed three different bibliographic databases looking for cancer-associated SCI case reports and case series. Data regarding age, sex, cardiovascular risk factors (CVRF), history of known cancer, infarction localization, spinal cord syndrome, Zalewski criteria classification, mechanism of ischemia, diagnostic tests, treatment and functional outcome were registered. A statistical analysis was carried out to identify factors related to mortality and survival time. RESULTS A total of 48 articles met the inclusion criteria and 52 patients were identified. The median age was 62 years. The most frequent neoplasm was intravascular large B-cell lymphoma. The median survival time was 17.4 weeks and the cumulative probability of survival at 12 months was 16.3%. In the group of deceased patients there was a higher proportion of malignant neoplasms than in those who survived (94.7% vs. 5.3%, p < 0.01). There were no statistically significant differences in terms of mortality or survival time depending on age, previously known cancer or CVRF. CONCLUSION Cancer-associated SCI entails a poor outcome. Mortality is increased in patients with malignant neoplasm. No other prognosis factors could be identified.
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Affiliation(s)
| | - Alejandro Rivero-de-Aguilar
- Department of Neurology, University Hospital of the Canary Islands, carretera Ofra S/N, La Laguna, Tenerife, Spain
| | - Leonor Varela-Lema
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Praza do Obradoiro, Santiago de Compostela, A Coruña, Spain; Consortium for Biomedical Research in Respiratory Diseases (CIBER de Enfermedades Respiratorias/CibeRes), Av. de Monforte de Lemos 3-5, Madrid, Spain
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18
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Seystahl K, Gramatzki D, Wanner M, Weber SJ, Hug A, Luft AR, Rohrmann S, Wegener S, Weller M. A risk model for prediction of diagnosis of cancer after ischemic stroke. Sci Rep 2023; 13:111. [PMID: 36596831 PMCID: PMC9810715 DOI: 10.1038/s41598-022-26790-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 12/20/2022] [Indexed: 01/05/2023] Open
Abstract
It remains controversial which characteristics may predict occult cancer in stroke patients. Characteristics of patients with ischemic stroke registered in the Zurich Swiss Stroke Registry (2014 to 2016) were tested for associations with cancer diagnosis after stroke with consideration of death as competing risk for cancer diagnosis. Among 1157 patients, 34 (3%) and 55 patients (5%) were diagnosed with cancer within 1 and 3 years after stroke. Levels of white blood cells (WBC) > 9,600/µl (subdistribution hazard ratio (SHR) 3.68, p = 0.014), platelets > 400,000/µl (SHR 7.71, p = 0.001), and d-dimers ≥ 3 mg/l (SHR 3.67, p = 0.007) were independently associated with cancer diagnosis within 1 year after stroke. Occurrence of ischemic lesions in ≥ 2 vascular territories not attributed to cardioembolic etiology was associated with cancer diagnosed within 1 year after stroke in univariable analysis (SHR 3.69, p = 0.001). The area under the curve of a score from these parameters (score sum 0-4) was 0.73. A score of ≥ 2 had a sensitivity of 43% and specificity of 92% for prediction of cancer diagnosis within 1 year after stroke. We suggest further validation of a score of WBC, platelets, d-dimers and multiple ischemic lesions without cardioembolic stroke etiology for prediction of cancer diagnosis after stroke.
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Affiliation(s)
- Katharina Seystahl
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland
| | - Dorothee Gramatzki
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland
| | - Miriam Wanner
- grid.7400.30000 0004 1937 0650Cancer Registry of the Cantons of Zurich, Zug, Schaffhausen and Schwyz, University Hospital and University of Zurich, Zurich, Switzerland
| | - Sung Ju Weber
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland
| | - Alessia Hug
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland
| | - Andreas R. Luft
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland ,grid.512634.7Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Sabine Rohrmann
- grid.7400.30000 0004 1937 0650Cancer Registry of the Cantons of Zurich, Zug, Schaffhausen and Schwyz, University Hospital and University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland
| | - Michael Weller
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland
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19
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Zedde M, Portaro G, Ferri L, Cavallieri F, Napoli M, Moratti C, Piazza F, Valzania F, Pascarella R. Neurovascular Manifestations of Iron-Deficient Anemia: Narrative Review and Practical Reflections through a Teaching Case. J Clin Med 2022; 11:jcm11206088. [PMID: 36294407 PMCID: PMC9605151 DOI: 10.3390/jcm11206088] [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: 08/09/2022] [Revised: 10/05/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022] Open
Abstract
Anemia is one of the most frequent diseases worldwide, affecting one-third of the general population. Anemia in general and in particular, iron-deficient anemia (IDA), has been associated to a higher risk of thrombotic manifestations, including ischemic stroke and cerebral venous thrombosis (CVT), as well as systemic extra-cerebral arterial and venous thrombosis. Despite these data, anemia is seldom considered as an etiological factor of stroke. An individual case encompassing all known neurovascular and systemic arterial and venous thrombotic manifestations related to IDA is presented with the focus on clinical reasoning issues in the diagnostic pathways, starting from the neuroradiological signs. The main questions have been identified and addressed in a narrative review of the most relevant data in the literature from a pragmatic and clinical viewpoint. The presented case concerns a 46-year-old man admitted to the Stroke Unit because of acute ischemic stroke with multiple thrombi in large intracranial and extracranial vessels, multifocal ischemic lesions in several arterial territories and the concurrent finding of asymptomatic CVT, pulmonary embolism with lung infarction and aortic thrombosis. An extended diagnostic work-up excluded the main etiologies (arterial dissection, cardiac embolism, genetic and acquired prothrombotic disorders, such as cancer and antiphospholipid syndrome), except for a severe IDA, such as to require blood transfusions followed by anticoagulant therapy for the several thrombotic manifestations. Neuroimaging and systemic vascular findings have been analyzed, and the main issues proposed by the case in the diagnostic pathway have been identified and discussed in a pragmatic clinical road map reviewing the data provided by the literature. Conclusions: IDA is a common but treatable condition that, independently or synergically, may increase the risk of thrombotic events. The diagnostic and therapeutic approach has not yet been defined, and each case should be individually addressed in a pragmatic clinical road map.
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Affiliation(s)
- Marialuisa Zedde
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
- Correspondence: or
| | - Giacomo Portaro
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Laura Ferri
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d’Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Francesco Cavallieri
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Manuela Napoli
- Neuroradiology Unit, Radiology Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Claudio Moratti
- Neuroradiology Unit, Radiology Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Fabrizio Piazza
- CAA and AD Translational Research and Biomarkers Laboratory, School of Medicine and Surgery, University of Milano—Bicocca, Via Cadore 48, 20900 Monza, Italy
| | - Franco Valzania
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, Radiology Department, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
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20
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Chen YJ, Dong RG, Zhang MM, Sheng C, Guo PF, Sun J. Cancer-related stroke: Exploring personalized therapy strategies. Brain Behav 2022; 12:e2738. [PMID: 35938982 PMCID: PMC9480895 DOI: 10.1002/brb3.2738] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cancer and ischemic stroke are two common diseases that threaten human health and have become the main causes of death in the world. It is estimated that one-in-ten patients with ischemic stroke have concomitant cancer, and this incidence is expected to increase as improvements in medical technology extends the life expectancy of cancer patients. DISCUSSION Cancer-related stroke (CRS) refers to unexplained ischemic stroke in patients with active cancer that cannot be explained by current stroke mechanisms. Available evidence suggests that CRS accounts for 5-10% of embolic stroke of undetermined source (ESUS). Although the incidence of CRS is gradually increasing, its underlying pathogenesis remains unclear. Also, there is no consensus on acute treatment and secondary prevention of stroke. CONCLUSION In this review, we retrospectively analyzed the incidence, mechanisms of CRS, its potential as a new stroke subtype, options for acute treatment, secondary prevention strategies, and disease progression, with the aim of attempting to explore personalized therapy strategies.
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Affiliation(s)
- Yu-Jie Chen
- Department of Neurological Rehabilitation, Xuzhou Central Hospital, Xuzhou city, P.R. China
| | - Rui-Guo Dong
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou city, P.R. China
| | - Meng-Meng Zhang
- Department of Neurological Rehabilitation, Xuzhou Central Hospital, Xuzhou city, P.R. China
| | - Chao Sheng
- Department of Neurological Rehabilitation, Xuzhou Central Hospital, Xuzhou city, P.R. China
| | - Peng-Fei Guo
- Department of Neurological Rehabilitation, Xuzhou Central Hospital, Xuzhou city, P.R. China
| | - Jie Sun
- Department of Neurological Rehabilitation, Xuzhou Central Hospital, Xuzhou city, P.R. China
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21
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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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22
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Predicting 10-year stroke mortality: development and validation of a nomogram. Acta Neurol Belg 2022; 122:685-693. [PMID: 34406610 PMCID: PMC9170668 DOI: 10.1007/s13760-021-01752-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/12/2021] [Indexed: 11/02/2022]
Abstract
Predicting long-term stroke mortality is a clinically important and unmet need. We aimed to develop and internally validate a 10-year ischaemic stroke mortality prediction score. In this UK cohort study, 10,366 patients with first-ever ischaemic stroke between January 2003 and December 2016 were followed up for a median (interquartile range) of 5.47 (2.96-9.15) years. A Cox proportional-hazards model was used to predict 10-year post-admission mortality. The predictors associated with 10-year mortality included age, sex, Oxfordshire Community Stroke Project classification, estimated glomerular filtration rate (eGFR), pre-stroke modified Rankin Score, admission haemoglobin, sodium, white blood cell count and comorbidities (atrial fibrillation, coronary heart disease, heart failure, cancer, hypertension, chronic obstructive pulmonary disease, liver disease and peripheral vascular disease). The model was internally validated using bootstrap resampling to assess optimism in discrimination and calibration. A nomogram was created to facilitate application of the score at the point of care. Mean age (SD) was 78.5 ± 10.9 years, 52% female. Most strokes were partial anterior circulation syndromes (38%). 10-year mortality predictors were: total anterior circulation stroke (hazard ratio, 95% confidence intervals) (2.87, 2.62-3.14), eGFR < 15 (1.97, 1.55-2.52), 1-year increment in age (1.04, 1.04-1.05), liver disease (1.50, 1.20-1.87), peripheral vascular disease (1.39, 1.23-1.57), cancers (1.37, 1.27-1.47), heart failure (1.24, 1.15-1.34), 1-point increment in pre-stroke mRS (1.20, 1.17-1.22), atrial fibrillation (1.17, 1.10-1.24), coronary heart disease (1.09, 1.02-1.16), chronic obstructive pulmonary disease (1.13, 1.03-1.25) and hypertension (0.77, 0.72-0.82). Upon internal validation, the optimism-adjusted c-statistic was 0.76 and calibration slope was 0.98. Our 10-year mortality model uses routinely collected point-of-care information. It is the first 10-year mortality score in stroke. While the model was internally validated, further external validation is also warranted.
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23
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Izumi T, Nanaura H, Iguchi N, Ozaki M, Sugie K. Serum Alkaline Phosphatase in Cryptogenic Stroke Cases with Active Cancer. Intern Med 2022; 61:639-646. [PMID: 35228475 PMCID: PMC8943387 DOI: 10.2169/internalmedicine.7550-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective We assessed the relationship between the levels of serum alkaline phosphatase, which is often increased with biliary obstruction and bone metastasis, and active cancer in patients with cryptogenic stroke. Methods Serum alkaline phosphatase levels in patients with cryptogenic stroke sampled upon admission were measured using the Japan Society of Clinical Chemistry method used in Japan. Active cancer was defined as a new diagnosis, treatment, progression, or recurrence within six months before admission or metastatic cancer. Multivariate logistic regression analyses were performed to explore the relationship between serum alkaline phosphatase and active cancer in these patients. Results Among the 249 patients classified as having cryptogenic stroke, 64 had active cancer. Patients with cryptogenic stroke with active cancer had significantly higher serum alkaline phosphatase levels (486±497 vs. 259±88.2 U/L; p<0.001) than those without cancer. Multivariate logistic analysis revealed that serum alkaline phosphatase levels ≥286 U/L were associated with cryptogenic stroke with active cancer [odds ratio (OR), 2.669, 95% confidence interval (CI), 1.291-5.517; p=0.008] independent of age ≤70 years old (OR, 3.303, 95% CI, 1.569-6.994; p=0.002), male sex (OR, 0.806, 95% CI, 0.380-1.710; p=0.573), and serum D-dimer levels ≥2.6 μg/mL (OR, 18.78, 95% CI, 8.130-43.40; p<0.001). Conclusion In patients with cryptogenic stroke, high serum alkaline phosphatase levels may be related to active cancer.
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Affiliation(s)
- Tesseki Izumi
- Department of Neurology, Nara Medical University, Japan
| | | | | | - Maki Ozaki
- Department of Neurology, Nara Medical University, Japan
| | - Kazuma Sugie
- Department of Neurology, Nara Medical University, Japan
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24
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Kikuno M, Ueno Y, Takekawa H, Kanemaru K, Shimizu T, Kuriki A, Tateishi Y, Doijiri R, Shimada Y, Yamaguchi E, Koga M, Kamiya Y, Ihara M, Tsujino A, Hirata K, Hasegawa Y, Aizawa H, Hattori N, Urabe T. Distinction in Prevalence of Atherosclerotic Embolic Sources in Cryptogenic Stroke With Cancer Status. J Am Heart Assoc 2021; 10:e021375. [PMID: 34689573 PMCID: PMC8751843 DOI: 10.1161/jaha.120.021375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Cerebrovascular diseases are common comorbidities in patients with cancer. Although active cancer causes ischemic stroke by multiple pathological conditions, including thromboembolism attributable to Trousseau syndrome, the relationship between stroke and inactive cancer is poorly known. The aim of this study was to elucidate the different underlying pathogeneses of cryptogenic stroke in active and inactive patients with cancer, with detailed investigation by transesophageal echocardiography. Methods and Results CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for Embolic Stroke of Undetermined Source/Cryptogenic Stroke) registry is a multicenter registry including data of patients initially diagnosed as having cryptogenic stroke and undergoing transesophageal echocardiography. Patients were divided into active cancer, inactive cancer, and noncancer groups, and their clinical features were compared. Of the total 667 enrolled patients (age, 68.7±12.8 years; 455 men), 41 (6.1%) had active cancer, and 51 (7.5%) had a history of inactive cancer. On multinomial logistic regression analysis, infarctions in multiple vascular territories (odds ratio [OR], 2.73; 95% CI, 1.39–5.40) and CRP (C‐reactive protein) (OR, 1.10; 95% CI, 1.01–1.19) were independently associated with active cancer, whereas age (OR, 1.05; 95% CI, 1.01–1.08), contralateral carotid stenosis from the index stroke lesion (OR, 4.05; 95% CI, 1.60–10.27), calcification of the aortic valve (OR, 2.10; 95% CI, 1.09–4.05), and complicated lesion of the aortic arch (OR, 2.13; 95% CI, 1.11–4.10) were significantly associated with inactive cancer. Conclusions Patients with cancer were not rare in cryptogenic stroke. Although patients with active cancer had more multiple infarctions, patients with inactive cancer had more atherosclerotic embolic sources potentially causing arteriogenic strokes. Registration URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000032957.
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Affiliation(s)
- Muneaki Kikuno
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan.,Department of Neurology Tokyo Medical University Hospital Tokyo Japan
| | - Yuji Ueno
- Department of Neurology Juntendo University Faculty of Medicine Tokyo Japan
| | | | - Kodai Kanemaru
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan.,Department of Neurology Tokyo Medical University Hospital Tokyo Japan
| | - Takahiro Shimizu
- Department of Neurology St. Marianna University School of Medicine Kanagawa Japan
| | - Ayako Kuriki
- Department of Neurology Showa University Koto Toyosu Hospital Tokyo Japan
| | - Yohei Tateishi
- Department of Neurology and Strokology Nagasaki University Hospital Nagasaki Japan
| | - Ryosuke Doijiri
- Department of Neurology Iwate Prefectural Central Hospital Iwate Japan
| | - Yoshiaki Shimada
- Department of Neurology Juntendo University Urayasu Hospital Chiba Japan
| | - Eriko Yamaguchi
- Department of Neurology Iwate Prefectural Central Hospital Iwate Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
| | - Yuki Kamiya
- Department of Neurology Showa University Koto Toyosu Hospital Tokyo Japan
| | - Masafumi Ihara
- Department of Neurology National Cerebral and Cardiovascular Center Osaka Japan
| | - Akira Tsujino
- Department of Neurology and Strokology Nagasaki University Hospital Nagasaki Japan
| | - Koichi Hirata
- Department of Neurology Dokkyo Medical University Tochigi Japan
| | - Yasuhiro Hasegawa
- Department of Neurology St. Marianna University School of Medicine Kanagawa Japan
| | - Hitoshi Aizawa
- Department of Neurology Tokyo Medical University Hospital Tokyo Japan
| | - Nobutaka Hattori
- Department of Neurology Juntendo University Faculty of Medicine Tokyo Japan
| | - Takao Urabe
- Department of Neurology Juntendo University Urayasu Hospital Chiba Japan
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Clinical Features of Trousseau Syndrome With Cerebral Infarction as the Initial Manifestation. Neurologist 2021; 25:117-121. [PMID: 32925481 DOI: 10.1097/nrl.0000000000000275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE There are few reports of Trousseau syndrome with cerebral infarction as the initial manifestation before the discovery of the tumor, which is often missed and misdiagnosed, and there is no unified therapy. To explore the clinical features of the Trousseau syndrome and, among those features, the risk factors for cerebral infarction as the initial manifestation. METHODS This was a retrospective study of 416 consecutive patients with cerebral infarction and malignant tumor admitted at The First Affiliated Hospital of Xinxiang Medical University between January 2015 and December 2017. The patients were grouped as: (1) cerebral infarction as the initial manifestation; and (2) tumor as the initial manifestation. A multivariable logistic regression analysis was used to analyze the relationship between the clinical features (age, sex, characteristics of the infarction, characteristics of the tumors, treatments, depression, coagulopathy, The National Institute of Health stroke scale score, platelet count, red cell count, hemoglobin, atherosclerosis, and coagulation parameters) and the hypercoagulable state. RESULTS A total of 416 patients met the criteria were included: 212 (51.0%) in the group with cerebral infarction as the initial manifestation and 204 (49.0%) in the group with tumor as the initial manifestation. The multivariable analysis showed that metastatic cancer (odds ratio=2.517; 95% confidence interval, 1.193-5.311; P=0.015) and depressive state (odds ratio=3.158; 95% confidence interval, 1.522-6.551; P=0.002) were independently associated with the Trousseau syndrome with cerebral infarction as the main manifestation. CONCLUSIONS Trousseau syndrome with cerebral infarction as the initial manifestation was associated with metastatic cancer and depressive state. There was no difference in coagulation status between the 2 groups.
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Score for Predicting Active Cancer in Patients with Ischemic Stroke: A Retrospective Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5585206. [PMID: 34124248 PMCID: PMC8169246 DOI: 10.1155/2021/5585206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/01/2021] [Accepted: 05/18/2021] [Indexed: 12/21/2022]
Abstract
Background We aimed to examine the differences of clinical characteristics between patients with ischemic stroke with active cancer and those without cancer to develop a clinical score for predicting the presence of occult cancer in patients with ischemic stroke. Methods This retrospective study enrolled consecutive adult patients with acute ischemic stroke who were admitted to our department between December 2017 and January 2019. The demographic, clinical, laboratory, and neuroimaging characteristics were compared between patients with ischemic stroke with active cancer and those without cancer. Multivariate analysis was performed to identify independent factors associated with active cancer. Subsequently, a predictive score was developed using the areas under the receiver operating characteristic curves based on these independent factors. Finally, Bayesian decision theory was applied to calculate the posterior probability of active cancer for finding the best scoring system. Results Fifty-three (6.63%) of 799 patients with ischemic stroke had active cancer. The absence of a history of hyperlipidemia (odds ratio (OR) = 0.17, 95% confidence interval (CI): 0.06-0.48, P < 0.01), elevated serum fibrinogen (OR = 1.72, 95% CI: 1.33-2.22, P < 0.01) and D-dimer levels (OR = 1.43, 95% CI: 1.24-1.64, P <0.01), and stroke of undetermined etiology (OR = 22.87, 95% CI: 9.91-52.78, P < 0.01) were independently associated with active cancer. A clinical score based on the absence of hyperlipidemia, serum fibrinogen level of ≥4.00 g/L, and D-dimer level of ≥2.00 μg/mL predicted active cancer with an area under the curve of 0.83 (95% CI: 0.77-0.89, P < 0.01). The probability of active cancer was 59% at a supposed prevalence of 6.63%, if all three independent factors were present in a patient with ischemic stroke. Conclusions We devised a clinical score to predict active cancer in patients with ischemic stroke based on the absence of a history of hyperlipidemia and elevated serum D-dimer and fibrinogen levels. The use of this score may allow for early intervention. Further research is needed to confirm the implementation of this score in clinical settings.
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Seystahl K, Hug A, Weber SJ, Kapitza S, Gramatzki D, Wanner M, Katan M, Luft AR, Rohrmann S, Wegener S, Weller M. Cancer is associated with inferior outcome in patients with ischemic stroke. J Neurol 2021; 268:4190-4202. [PMID: 33945004 PMCID: PMC8505392 DOI: 10.1007/s00415-021-10528-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/22/2021] [Indexed: 11/12/2022]
Abstract
Background Whether patients with stroke and cancer exhibit specific characteristics has remained controversial. Methods Medical records of patients with ischemic stroke in 2014 or 2015 registered in the Swiss Stroke Registry of Zurich were retrospectively analyzed and integrated with regional cancer registry data. Associations of clinical and outcome parameters with cancer diagnosed up to 5 years prior to stroke were tested. Results Of 753 patients with ischemic stroke, 59 patients with cancer were identified. History of venous thromboembolism (p < 0.001) was associated with cancer while age and cardiovascular risk factors were not. Higher levels of D-dimers (p = 0.001), erythrocyte sedimentation rate (p = 0.003), C-reactive protein (CRP) (p < 0.001), and lower levels of hemoglobin (p = 0.003) were associated with cancer. For platelets, pathologically low (p = 0.034) or high levels (p < 0.001) were linked to cancer. Modified Rankin scale (mRS) scores ≥ 4 on admission and at follow-up were more frequent in cancer patients (p = 0.038 and p = 0.001). Poor post-stroke survival was associated with cancer (HR 2.2, p < 0.001). Multivariable analysis identified venous thromboembolism (OR 5.1), pathologic platelet count (OR = 2.9), low hemoglobin (OR 2.5) and elevated CRP (OR 1.8) as independently associated with cancer. In multivariable Cox regression, risk for death was associated with cancer (HR 1.7), low hemoglobin (HR 2.6), mRS on admission ≥ 4 (HR 1.9), pathologic platelet count (HR 1.6), female sex (HR 1.7), and elevated CRP (HR 1.4). Conclusions Considering cancer as a cofactor for post-stroke outcome may impact clinical decision making. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10528-3.
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Affiliation(s)
- Katharina Seystahl
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland.
| | - Alessia Hug
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Sung Ju Weber
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Sandra Kapitza
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Dorothee Gramatzki
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Miriam Wanner
- Cancer Registry of the Canton of Zurich, Zug, Schaffhausen and Schwyz, University Hospital and University of Zurich, Zurich, Switzerland
| | - Mira Katan
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Andreas R Luft
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland.,Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Sabine Rohrmann
- Cancer Registry of the Canton of Zurich, Zug, Schaffhausen and Schwyz, University Hospital and University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
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Guan T, Zhang H, Yang J, Lin W, Wang K, Su M, Peng W, Li Y, Lai Y, Liu C. Increased Risk of Cardiovascular Death in Breast Cancer Patients Without Chemotherapy or (and) Radiotherapy: A Large Population-Based Study. Front Oncol 2021; 10:619622. [PMID: 33585246 PMCID: PMC7876382 DOI: 10.3389/fonc.2020.619622] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/09/2020] [Indexed: 12/21/2022] Open
Abstract
Background Cardiovascular death (CVD) in breast cancer patients without chemotherapy (CT) or (and) radiotherapy (RT) has not been studied yet. This study evaluates the correlation between breast cancer and CVD risk independent of chemotherapy or (and) radiotherapy. Methods Data of female breast cancer patients without receiving CT or RT were retrieved from the Surveillance, Epidemiology, and End Result (SEER) database (2004–2015). Data were divided into two cohorts: tumor resection cohort and no resection cohort. The CVD risk in patients was expressed as standardized mortality ratios (SMRs). A 1:1 propensity score matching (PSM) was applied to balance inter-group bias, and competing risk regressions were utilized to evaluate the impact of tumor resection on CVD. Results The CVD risk was significantly higher (SMR = 2.196, 95% CI: 2.148–2.245, P<0.001) in breast cancer patients who did not receive CT or RT compared to the general population. Breast cancer patients without tumor resection showed higher CVD risk than patients who underwent tumour resection (tumor resection SMR = 2.031, 95% CI: 1.983–2.079, P<0.001; no resection SMR = 5.425, 95% CI: 5.087–5.781, P<0.001). After PSM, the CVD risk among patients without tumor resection indicated an increase of 1.165-fold compared to patients with tumor resection (HR=1.165, 95% CI: 1.039–1.306, P=0.009). Conclusions Female breast cancer patients are at higher risk of CVD despite unexposure to cardio-toxic CT or RT. However, female breast cancer patients subjected to tumor resection have decreased CVD risk. These results indicated that monitoring female breast cancer patients not receiving RT or CT might serve as a preventative measure against CVD.
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Affiliation(s)
- Tianwang Guan
- Department of Cardiology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China.,Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China.,Department of Cardiology, Laboratory of Heart Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Hanbin Zhang
- Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China.,Department of Clinical Medicine, Clinical Medical School, Guangzhou Medical University, Guangzhou, China
| | - Jinming Yang
- Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China.,Department of Clinical Medicine, Clinical Medical School, Guangzhou Medical University, Guangzhou, China
| | - Wenrui Lin
- Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China.,Department of Clinical Medicine, Clinical Medical School, Guangzhou Medical University, Guangzhou, China
| | - Kenie Wang
- The First Department of Breast Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
| | - Miao Su
- Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China.,Department of Clinical Medicine, Clinical Medical School, Guangzhou Medical University, Guangzhou, China
| | - Weien Peng
- Department of Clinical Medicine, Clinical Medical School, Guangzhou Medical University, Guangzhou, China
| | - Yemin Li
- Department of Clinical Medicine, Clinical Medical School, Guangzhou Medical University, Guangzhou, China
| | - Yanxian Lai
- Department of Cardiology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China.,Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Cheng Liu
- Department of Cardiology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China.,Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
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Endovascular Therapy of Acute Ischemic Stroke in Patients with Large-Vessel Occlusion Associated with Active Malignancy. J Stroke Cerebrovasc Dis 2020; 30:105455. [PMID: 33242784 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105455] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/22/2022] Open
Abstract
PURPOSE There is limited data on the effectiveness of endovascular therapy (EVT) in stroke patients with active malignancy. In this study, we investigated the outcome of EVT for acute ischemic stroke for patients with active malignancy compared to those without malignancy. METHODS We selected patients who underwent EVT for acute ischemic stroke between January 2015 and July 2019. Patients were divided into two groups, those with active malignancy (oncology group - OG) and those without (non-oncology group, NOG). RESULTS 300 patients were included in this study. There were 19 EVT procedures (18 patients) in the OG and 285 procedures (282 patients) in the NOG. There was no difference in recanalization success rate (mTICI 2b & 3) between the groups: 94.7% versus 80.9% in OG and NOG respectively (p = 0.13). Success rate using the direct aspiration (ADAPT) technique of EVT was not different between compared groups (42.9% versus 67.7%; p = 0.18). However, when using smaller-caliber aspiration devices, ADAPT was less successful in OG (0.0% versus 64.7%, p < 0.05). There was no difference in recanalization success rate of EVT when using a stent-retriever or combined technique. Patients in the OG had a less favorable functional outcome than in the NOG group (mRS 0-2 at 90-days post event: 22.2% versus 48.2%, p < 0.05) CONCLUSION: The technical success rate of EVT in patients with active malignancy is similar to the general population of stroke patients. Interestingly, the success rate of EVT using the ADAPT technique was lower in the OG when using smaller caliber aspiration devices.
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Salazar-Camelo RA, Moreno-Vargas EA, Cardona AF, Bayona-Ortiz HF. Ischemic stroke: A paradoxical manifestation of cancer. Crit Rev Oncol Hematol 2020; 157:103181. [PMID: 33264715 DOI: 10.1016/j.critrevonc.2020.103181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 10/01/2020] [Accepted: 11/11/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Approximately 5-10 % of the patients with cryptogenic stroke have an underlying malignancy. Stroke as a complication of cancer increases the morbidity and mortality among cancer patients, leading to increased disability and healthcare costs. OBJECTIVE To provide elements to guide physicians for when to suspect and evaluate for cancer in stroke patients. DEVELOPMENT We performed a narrative review, portrayed in a question-answer format, to report relevant aspects of cancer stroke patients in the clinical practice and provide a guide based on the state-of-the-art literature. Conventional stroke mechanisms are only found in a fraction of patients with cancer. Although cardiovascular risk factors play an important role in both cancer and stroke pathogenesis, the recognition of more specific cancer-associated risk factors raises clinical suspicion for occult malignancy. We also expose the main type location and histology of tumors that are most commonly associated with stroke as well as potential blood biomarkers and current treatment considerations in the scenario of cancer associated stroke. CONCLUSION Subjects with active cancer are a patient population at increased risk for developing an ischemic stroke. Cryptogenic stroke patients have a higher risk of cancer diagnosis in the following 6-12 months. We recommend a multidisciplinary approach considering the high probability of a hidden malignancy and running a comprehensive evaluation including neurologic imaging, serological biomarkers and tight follow up.
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Affiliation(s)
- Ruth A Salazar-Camelo
- Neurology Department, Hospital Universitario Fundación Santa Fe Colombia, Bogotá, Colombia; Universidad los Andes Colombia, School of Medicine, Bogotá, Colombia.
| | - Eder A Moreno-Vargas
- Neurology Department, Hospital Universitario Fundación Santa Fe Colombia, Bogotá, Colombia; Universidad los Andes Colombia, School of Medicine, Bogotá, Colombia.
| | - Andrés F Cardona
- Clinical and Traslational Oncology Group, Clínica del Country, Bogotá, Colombia; Foundation for Clinical and Applied Cancer Research - FICMAC, Bogotá, Colombia; Molecular Oncology and Biology Systems Reasearch Group (Fox-G), Universidad El Bosque, Bogotá, Colombia.
| | - Hernán F Bayona-Ortiz
- Neurology Department, Hospital Universitario Fundación Santa Fe Colombia, Bogotá, Colombia; Universidad los Andes Colombia, School of Medicine, Bogotá, Colombia; Universidad El Bosque Colombia, School of Medicine, Neurology program, Bogotá, Colombia.
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Specificities of acute phase stroke management in the elderly. Rev Neurol (Paris) 2020; 176:684-691. [PMID: 32980154 DOI: 10.1016/j.neurol.2020.07.006] [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: 10/25/2019] [Revised: 06/22/2020] [Accepted: 07/06/2020] [Indexed: 11/21/2022]
Abstract
Health professionals are currently facing the challenge of managing an increasing number of old patients presenting with acute stroke, due to rapid aging of the population. Compared to their younger counterparts, elderly patients differ in many ways in the setting of acute stroke. Apart from a striking high stroke incidence, which increases exponentially as age increases, cardioembolism also becomes, as patients age, the main cause of ischemic stroke. Delirium, which can challenge the diagnosis, is frequent at the acute phase of stroke, and may be related to an underlying dementia, which is almost exclusively observed in the elderly during stroke. At all levels, management of elderly stroke patients is suboptimal, especially when they are cognitively impaired, with insufficiencies including admission to stroke units, applying standards of care and investigation, reperfusion therapy for ischemic stroke, and finally transfer to rehabilitation centers. A paradigm shift must take place to limit age-related discrimination for acute-phase management of stroke.
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Sorigue M, Miljkovic MD. Atrial Fibrillation and Stroke Risk in Patients With Cancer: A Primer for Oncologists. J Oncol Pract 2020; 15:641-650. [PMID: 31825754 DOI: 10.1200/jop.18.00592] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Cancer and atrial fibrillation (AF) are common conditions, but for patients affected with both, there is a lack of data about management of anticoagulation and cerebrovascular outcomes. In the first section of this review, we summarize the most relevant studies on stroke risk and management of AF in patients with active cancer, attempting to answer questions of whether to anticoagulate, whom to anticoagulate, and what agents to use. In the second section of the review, we suggest a decision algorithm on the basis of the available evidence and provide practical recommendations for each of the anticoagulant options. In the third section, we discuss the limitations of the available evidence. On the basis of low-quality evidence, we find that patients with cancer and AF have a risk of stroke similar to that of the general population but a substantially higher risk of bleeding regardless of the anticoagulant agent used; this makes anticoagulation-related decisions complex and evidence from the general population not immediately applicable. In general, we suggest stopping anticoagulation in patients with high risk of bleeding and in those with a moderate bleeding risk without a high thromboembolic risk and recommend anticoagulation as in the general population for patients at a low risk for bleeding. However, regardless of initial therapy, we recommend reassessing whether anticoagulation should be given at each point in the clinical course of the disease. High-quality evidence to guide anticoagulation for AF in patients with cancer is needed.
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Affiliation(s)
- Marc Sorigue
- ICO-Hospital Germans Trias i Pujol.IJC, UAB, Badalona, Spain
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Cui C, Gao J, Li J, Yu M, Zhang H, Cui W. Value of TAT and PIC with D-dimer for cancer patients with metastasis. Int J Lab Hematol 2020; 42:387-393. [PMID: 32250048 DOI: 10.1111/ijlh.13194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 03/04/2020] [Accepted: 03/06/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The hypercoagulability of blood is related to the development and metastasis of cancer. High levels of D-dimer have been reported to be associated with the metastasis and poor prognoses of cancer. Here, we investigated the performance of biomarkers-TAT, PIC, TM, and tPAI·C by new method-for monitoring cancer patients with metastasis. METHODS A total of 197 cancer patients were enrolled. TM, TAT, PIC, and tPAI·C were detected by the chemiluminescence immunoassay. RESULTS Results showed that the levels of TAT and PIC were higher in the metastasis group than those in the nonmetastasis group (P < .01). In the nonmetastasis group, there were 16 patients with elevated levels of D-dimer. But, TAT and PIC in these 16 patients were all at normal level (<0.55 mg/L FEU). After dilution, D-dimer was also decreased to normal levels in these 16 patients. The ROC was used to show the performance of D-dimer, TAT, and PIC on indicating cancer with metastasis. The AUC of PIC was higher than that of D-dimer (0.825 vs. 0.770). The specificity and PPV of TAT and PIC were higher than those of D-dimer. Serial test of TAT, PIC, and D-dimer improved the specificity and positive predictive value to 90.91% [80.61%, 96.25%] and 89.29% [77.45%, 95.57%], respectively. CONCLUSION Combining TAT and PIC with D-dimer could be useful surveillance biomarkers for cancer with metastasis.
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Affiliation(s)
- Chanjuan Cui
- Department of Laboratory Medicine, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Gao
- Department of Laboratory Medicine, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Li
- Department of Laboratory Medicine, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mengyao Yu
- Department of Laboratory Medicine, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Zhang
- Department of Laboratory Medicine, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Cui
- Department of Laboratory Medicine, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Yuan Z, Cao D, Yu M, Zhou H, Zhang Y, Yang J, Shen K. Importance of Standard Treatment in Prognosis of Patients with Ovarian Cancer and Associated Cerebral Infarction. Clin Interv Aging 2020; 15:151-157. [PMID: 32103916 PMCID: PMC7014957 DOI: 10.2147/cia.s229236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/27/2019] [Indexed: 11/23/2022] Open
Abstract
Objective Data on the treatment of patients with ovarian cancer (OC) and associated cerebral infarction (CI) are extremely limited. The objectives were to investigate the risk factors for prognosis in patients with OC and associated CI. Methods We retrospectively reviewed the electronic medical records of patients with OC from January 2013 to November 2018 in Peking Union Medical Hospital. Results In total, 2632 inpatients were diagnosed with malignant ovarian cancer in our institution, and 30 patients (1.1%) were diagnosed with OC-associated CI. The median age was 60 years (range, 37–83). The standard treatment, according to National Comprehensive Cancer Network (NCCN) guidelines, was administered to 19 patients. The median follow-up time was 19.5 months (range, 1–59 months). In total, 17 patients experienced tumor progression, and 16 of them died. In univariate analysis, overall survival was significantly associated with the D-dimer level (P=0.017), FIGO stage (P=0.014), complete cytoreduction (P<0.000) and standard treatment (P<0.000). In multivariate analysis, the standard treatment remained an independent protective factor for death (hazard ratio=0.061, 95% confidence interval=0.007–0.537, P=0.012). Conclusion Although the prognosis of patients with OC and associated CI was poor, those who underwent the standard treatment still benefited.
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Affiliation(s)
- Zhen Yuan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Mei Yu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Huimei Zhou
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Ying Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jiaxin Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Keng Shen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Bang OY, Chung JW, Lee MJ, Seo WK, Kim GM, Ahn MJ. Cancer-Related Stroke: An Emerging Subtype of Ischemic Stroke with Unique Pathomechanisms. J Stroke 2020; 22:1-10. [PMID: 32027788 PMCID: PMC7005348 DOI: 10.5853/jos.2019.02278] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/05/2019] [Indexed: 01/20/2023] Open
Abstract
Systemic cancer and ischemic stroke are common conditions and two of the most frequent causes of death among the elderly. The association between cancer and stroke has been reported worldwide. Stroke causes severe disability for cancer patients, while cancer increases the risk of stroke. Moreover, cancer-related stroke is expected to increase due to advances in cancer treatment and an aging population worldwide. Because cancer and stroke share risk factors (such as smoking and obesity) and treatment of cancer can increase the risk of stroke (e.g., accelerated atherosclerosis after radiation therapy), cancer may accelerate conventional stroke mechanisms (i.e., atherosclerosis, small vessel disease, and cardiac thrombus). In addition, active cancer and chemotherapy may enhance thrombin generation causing stroke related to coagulopathy. Patients with stroke due to cancer-related coagulopathy showed the characteristics findings of etiologic work ups, D-dimer levels, and infarct patterns. In this review, we summarized the frequency of cancer-related stroke among patients with ischemic stroke, mechanisms of stroke with in cancer patients, and evaluation and treatment of cancer-related stroke. We discussed the possibility of cancer-related stroke as a stroke subtype, and presented the most recent discoveries in the pathomechanisms and treatment of stroke due to cancer-related coagulopathy.
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Affiliation(s)
- Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Translational and Stem Cell Research Laboratory on Stroke, Samsung Medical Center, Seoul, Korea
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Ji Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung-Ju Ahn
- Department of Hemato-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Gallo A, Galliazzo S, Grazioli S, Guasti L, Ageno W, Squizzato A. Epidemiology and secondary prevention of ischemic stroke in patients on antiplatelet drug: a retrospective cohort study. J Thromb Thrombolysis 2020; 48:336-344. [PMID: 31177486 DOI: 10.1007/s11239-019-01893-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
One-third to one-half of ischemic strokes occurred in patients taking antiplatelet drugs. The optimal therapeutic strategy for antithrombotic drugs remains uncertain and guidelines provide scarse recommendation. Therefore, aims of our study were to: (i) estimate the prevalence of patients who develop an ischemic stroke while on antiplatelet drugs, (ii) investigate potential factors associated with this phenomenon, (iii) describe management strategies in daily clinical practice. Consecutive adult patients admitted for acute ischemic stroke at the academic hospital of Varese, Italy, from January 2010 till December 2011 were included. Patients were retrospectively identified by searching the administrative database of the hospital. Odds ratios (ORs) and their 95% confidence intervals (CI) for identifying factors associated with dependent variable were estimated using univariate logistic regression. Any variable with a p value < 0.2 at univariate analysis was included in a multivariate model. A total of 419 patients were included. Patients with ischemic stroke while on antiplatelet drugs were 49.6%. The following baseline characteristics were associated with the occurrence of ischemic stroke in patients taking antiplatelet drugs: diabetes mellitus (DM), history of ischemic heart disease (IHD), age > 65 years and previous stroke or transient ischemic stroke (TIA). The following variables were significantly associated with a change of antithrombotic therapy at discharge: DM, history of IHD and previous stroke or TIA. Our study confirms that the occurrence of ischemic stroke during antiplatelet treatment is common and management of antithrombotic therapy is heterogeneous. Factors that may explain therapeutic failure include undetected cardioembolic sources, drug resistance, poor compliance, or the presence of diabetes, atherothrombotic disease, and advanced age. Randomized controlled trials are warranted to assess the optimal antithrombotic strategy for ischemic stroke occurred in patients taking antiplatelet drugs.
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Affiliation(s)
- Andrea Gallo
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese, Italy.
| | - Silvia Galliazzo
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese, Italy
| | - Stefano Grazioli
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese, Italy
| | - Luigina Guasti
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese, Italy
| | - Alessandro Squizzato
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese, Italy
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Galarza Fortuna GM, Singh A, Jacobs A, Ugalde I. Lung Adenocarcinoma Presenting as Multiple Thromboembolic Events: A Case Report and Review of the Literature. J Investig Med High Impact Case Rep 2020; 8:2324709620969482. [PMID: 33138640 PMCID: PMC7675902 DOI: 10.1177/2324709620969482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Patients with malignancy may present with significant thromboembolic
complications including deep vein thrombosis (DVT), pulmonary
embolism, arterial thrombosis, nonbacterial thrombotic endocarditis,
and stroke due to abnormal coagulation cascades. Although these events
are typically recognized later in the disease process, complications
of a hypercoagulable state can rarely present as the first
manifestation of an occult malignancy. We report a case of a young
male who was ultimately found to have an aggressive form of lung
adenocarcinoma after the initial presentation of multiple
thromboembolic events. DVT and stroke as an initial presentation of an
active lung adenocarcinoma in a young patient is extremely rare as
patients presenting in a hypercoagulable state usually are older.
Though testing for a hypercoagulable state is not recommended for the
first unprovoked DVT, clinicians should be prompted to screen for
malignancy in the setting of cryptogenic strokes, especially in
younger patients with no prior risk factors.
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Affiliation(s)
- Gliceida M. Galarza Fortuna
- Mount Sinai Medical Center, Miami
Beach, FL, USA
- Gliceida M. Galarza Fortuna, MD,
Department of Internal Medicine, Mount Sinai Medical Center, 4300
Alton Road, Miami Beach, FL 33140, USA.
| | - Anita Singh
- Mount Sinai Medical Center, Miami
Beach, FL, USA
| | - Adam Jacobs
- Mount Sinai Medical Center, Miami
Beach, FL, USA
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Clinical Characteristics and Risk Factors of Lung Cancer-Associated Acute Ischemic Stroke. BIOMED RESEARCH INTERNATIONAL 2019; 2019:6021037. [PMID: 31930131 PMCID: PMC6935791 DOI: 10.1155/2019/6021037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/07/2019] [Accepted: 10/16/2019] [Indexed: 12/24/2022]
Abstract
Objective To research the clinical characteristics and risk factors of lung cancer-associated acute ischemic stroke (LCA-AIS). Methods Patients diagnosed with LCA-AIS, simple lung cancer, and simple AIS were enrolled. The primary information, laboratory results, tumor histopathology, neurological deficits, and survival time of the patients were collected and analyzed. Results (1) In the LCA-AIS group, the pathology of 69.56% patients were adenocarcinoma, and the proportion of poorly differentiated patients was significantly more than that in moderately differentiated or highly differentiated. The number of stage IV lung cancer patients in the LCA-AIS group was significantly more common than in other stages. (2) 56.52% of patients with lung cancer were diagnosed before AIS, and the peak of AIS attack was 1–6 months after the diagnosis of lung cancer. (3) The independent risk factors of LCA-AIS were CYFRA-211 (OR 1.070; 95% confidence interval 1.005, 1.139; p = 0.035), TT (OR 1.275; 95% confidence interval 1.089, 1.493; p = 0.003), and Hct (OR 0.878; 95% confidence interval 0.779, 0.990; p = 0.034), making ROC curve, suggesting the area under the curve is 0.871. (4) The neurological deficit of patients in the LCA-AIS group was similar to the simple AIS group and could not be identified by the severity of neurological deficits. (5) The median survival time of LCA-AIS group patients was five months (95% confidence interval 3.796, 6.204). There were statistical differences in survival time between LCA-AIS group and simple AIS group patients (p < 0.001). Conclusions The interaction between lung cancer and AIS may shorten patients' life expectancy and worsen their quality of life.
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Abstract
PURPOSE OF REVIEW To review the latest information about the interactions between cancer and cerebrovascular disease. RECENT FINDINGS Additional data support the finding that both ischemic and hemorrhagic stroke are important complications of cancer or its treatment. Reperfusion therapy is being given successfully to patients with stroke complicating cancer. Hemorrhagic stroke may occur with metastatic disease to the brain, coagulopathies from cancer, in particular leukemia, or as complications of chemotherapy. Ischemic stroke also may be a complication of metastatic disease with local invasion of vessels, a pro-thrombotic disorder such as non-bacterial thrombotic endocarditis (NBTE) or disseminated intravascular coagulation (DIC), or secondary to chemotherapy. Stroke also is a potential consequence of radiation therapy to the head and neck. Venous sinus thrombosis may develop with hematologic malignancies or chemotherapy. Although many patients will have a history of cancer at the time of stroke, a cerebrovascular event may be the initial manifestation of a malignancy.
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Wang F, Hu XY, Cui ZM, Fang XM, Dai Z, Wang T, Guo DL. Clinical and Imaging Characteristics of Malignant Tumor Concurrent with Stroke. Cancer Biother Radiopharm 2019; 34:504-510. [PMID: 31295003 DOI: 10.1089/cbr.2019.2853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objectives: The present study aimed to retrospectively compare the clinical and imaging characteristics and laboratory data of patients with malignant tumor concurrent with acute ischemic stroke (IS) and patients with cerebral infarction only, and to analyze the potential related risk factors. Method: A total of 126 patients with acute cerebral infarction concurrent with malignant tumor were collected and assigned to the malignant tumor group. In addition, 120 patients hospitalized for routine acute IS during the same period were randomly selected as the control group. Demographic data and common risk factors of cerebrovascular disease, laboratory data, and imaging characteristics in these two groups were compared. Results: In the malignant tumor group, the age of onset was relatively low, and the National Institutes of Health Stroke Scale score, 90 d recurrence rate, and fatality rate were higher than for those in the control group (p < 0.05). However, most patients had no traditional risk factors of stroke. Biochemical results revealed that the peripheral hemoglobin of patients with malignant tumor and cerebral infarction was lower than for those in the control group (p < 0.05). Furthermore, the levels of D-dimer, fibrinogen, tumor markers CA125, CA199, and carcinoembryonic antigen were significantly elevated, and the difference was statistically significant (p < 0.05). Magnetic resonance imaging results revealed that multiple intracranial infarcts were more common in patients in the malignant tumor group, and the difference was statistically significant compared with patients with cerebral infarction only (p < 0.05). Conclusion: Patients with cancer and IS had fewer traditional stroke risk factors but more anemia as well as higher D-dimer level, tumor marker rate, short-term mortality, and stroke recurrence rate. Furthermore, lower age of onset and other characteristics, including multiple intracranial infarcts, can be regarded as important characteristics of such patients.
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Affiliation(s)
- Feng Wang
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Xiao-Yun Hu
- Department of Radiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Zhi-Ming Cui
- Department of Radiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Xiang-Ming Fang
- Department of Radiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Zheng Dai
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Tao Wang
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Dao-Liu Guo
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
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Qin QX, Cheng XM, Lu LZ, Wei YF, Wang DC, Li HH, Li GH, Liang HB, Li SY, Chen L, Liang ZJ. Biomarkers and potential pathogenesis of colorectal cancer-related ischemic stroke. World J Gastroenterol 2018; 24:4950-4958. [PMID: 30487704 PMCID: PMC6250925 DOI: 10.3748/wjg.v24.i43.4950] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/02/2018] [Accepted: 11/08/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the specific biomarkers and potential pathogenesis of colorectal cancer-related ischemic stroke (CRCIS).
METHODS A retrospective study was conducted on CRCIS patients (colorectal cancer patients with ischemic stroke without conventional stroke risk factors) registered at seven centers between January 2007 and December 2017. Clinical data and laboratory and imaging findings were compared with age- and sex- matched patients with colorectal cancer (CRC) without ischemic stroke that were admitted to the same hospital during the same period. Univariate and multivariate analyses were performed to analyze the independent risk factors for CRCIS. A receiver operator characteristic curve was configured to calculate the optimal cut-off value of the products of the independent risk factors for CRCIS.
RESULTS A total of 114 CRCIS patients and 114 CRC patients were included. Multiple lesions in multiple vascular territories were common in CRCIS patients (71, 62.28%). The levels of plasma D-dimer, carcinoembryonic antigen (CEA), cancer antigen 125, and neutrophil count were significantly higher in CRCIS patients than in CRC patients. Multiple logistic regression analysis revealed that plasma D-dimer levels [odds ratio (OR) = 1.002, 95% confidence interval (CI): 1.001-1.003, P < 0.001], CEA levels (OR = 1.011, 95%CI: 1.006-1.015, P < 0.001), and neutrophil count levels (OR = 1.626, 95%CI: 1.268-2.087, P < 0.001) were independent risk factors for CRCIS. In addition, receiver operator characteristic curve revealed that the area under curve for the products of plasma D-dimer, CEA, and neutrophil count was 0.889 ± 0.022 (95%CI: 0.847-0.932, P < 0.001), and the optimal cut-off value for the product was 252.06, which was called the CRCIS Index, with a sensitivity of 86.0% and specificity of 79.8%.
CONCLUSION Hypercoagulability induced by elevated CEA and neutrophils may be an important cause of CRCIS. The CRCIS index, which serves as a biomarker of CRCIS, needs further study.
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Affiliation(s)
- Qi-Xiong Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Province, China
| | - Xue-Min Cheng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Province, China
| | - Li-Zhi Lu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Province, China
| | - Yun-Fei Wei
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, Nanning 530007, Guangxi Province, China
| | - Da-Cheng Wang
- Department of Neurology, The Ninth Affiliated Hospital of Guangxi Medical University, Beihai 536000, Guangxi Province, China
| | - Hai-Hua Li
- Department of Neurology, Fusui County People’s Hospital, Chongzuo 532100, Guangxi Province, China
| | - Guo-Hui Li
- Department of Neurology, Wuzhou Red Cross Hospital, Wuzhou 543002, Guangxi Province, China
| | - Hong-Bin Liang
- Department of Neurology, Cenxi People’s Hospital, Cenxi 543200, Guangxi Province, China
| | - Sheng-Yu Li
- Department of Neurology, Wuming County People’s Hospital, Nanning 530100, Guangxi Province, China
| | - Li Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Province, China
| | - Zhi-Jian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, Guangxi Province, China
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Hung YS, Chen JS, Chen YY, Lu CH, Chang PH, Chou WC. Incidence, Risk Factors, and Outcomes of Arterial Thromboembolism in Patients with Pancreatic Cancer Following Palliative Chemotherapy. Cancers (Basel) 2018; 10:cancers10110432. [PMID: 30424491 PMCID: PMC6267556 DOI: 10.3390/cancers10110432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Few studies have explored the association between pancreatic cancer and arterial thromboembolism (aTE). METHODS A total of 838 consecutive patients receiving palliative chemotherapy for pancreatic cancer between 2010 and 2016 were retrospectively enrolled. The clinical characteristics of patients were analyzed to determine the incidence, risk factors, and survival outcome of aTE in patients with pancreatic cancer. RESULTS aTE occurred in 42 (5.0%) of 838 patients. Patients with aTE had a worse survival outcome than those without (5.1 months versus 7.8 months, hazard ratio 1.53, 95% confidence interval [CI]: 1.12⁻2.09). Stage IV disease, high aspartate transaminase level, and comorbidity with hypertension or atrial fibrillation were four independent predictors of aTE. A concise predictive model stratified patients into low (0⁻1 predictor), intermediate (2 predictors), and high (3⁻4 predictors) risk groups. The hazard ratios for the comparison of patients in intermediate and high risk groups with those in low risk group were 4.55 (95% CI: 2.31⁻8.98), and 13.3 (95% CI: 5.63⁻31.6), respectively. CONCLUSION Patients with pancreatic cancer undergoing palliative chemotherapy have an increased risk of aTE. A predictive model showed that patients presented with 3 or 4 predictors had the highest risk for developing aTE.
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Affiliation(s)
- Yu-Shin Hung
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan 333, Taiwan.
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan 333, Taiwan.
| | - Yen-Yang Chen
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung 833, Taiwan.
| | - Chang-Hsien Lu
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Chiayi, Chiayi 612, Taiwan.
| | - Pei-Hung Chang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Keelung, Keelung 204, Taiwan.
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan 333, Taiwan.
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