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Fukunaga D, Fujinami J, Kishitani T, Tokuda N, Numa S, Nagakane Y. Absence of the Susceptibility Vessel Sign with Cancer-Associated Hypercoagulability-Related Stroke. AJNR Am J Neuroradiol 2024; 45:1427-1431. [PMID: 38816022 PMCID: PMC11448996 DOI: 10.3174/ajnr.a8363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/27/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND AND PURPOSE The susceptibility vessel sign, a hypointense signal on MR T2-weighted gradient-recalled echo images, is associated with erythrocyte-predominant thrombi, which are often present in cardioembolism. In contrast, cancer-associated hypercoagulability (CAH)-related stroke, which is presumably caused by fibrin-predominant thrombi, is associated with the absence of the susceptibility vessel sign. We hypothesized that the prevalence of the susceptibility vessel sign may be helpful in distinguishing CAH-related stroke from cardioembolism. This study attempted to validate this hypothesis and investigated the usefulness of the susceptibility vessel sign in differentiating CAH-related stroke from cardioembolism. MATERIALS AND METHODS We retrospectively studied patients with both CAH-related stroke (CAH group) and cardioembolism (cardioembolism group) who had major cerebral artery occlusion on MRA that was performed within 6 hours of stroke onset. All patients visited our department from 2015 to 2021. CAH-related stroke was defined as the following: 1) complication of active cancer, 2) pretreatment D-dimer value of >3 μg/mL, 3) multiple vascular territory infarctions, and 4) lack of any other specifically identified causes of stroke. We compared susceptibility vessel sign positivity rates within each group. Multivariable logistic regression analysis was used to assess the association between the absence of the susceptibility vessel sign and CAH-related stroke. RESULTS Of 691 patients with CAH-related stroke or cardioembolism, major cerebral artery occlusion was observed in 10 patients in the CAH group and 198 patients in the cardioembolism group. The absence of the susceptibility vessel sign was identified in 55 of 208 patients and was significantly more frequent in the CAH group versus the cardioembolism group (90% versus 24%, P < .05). For predicting CAH-related stroke, the absence of the susceptibility vessel sign demonstrated a sensitivity of 90% (95% CI, 59%-99%), specificity of 78% (95% CI, 71%-83%), a positive predictive value of 18% (95% CI, 10-31), a negative predictive value of 99% (95% CI, 96%-99%), and a likelihood ratio of 4.06. Multivariable logistic regression analysis revealed that the absence of the susceptibility vessel sign was independently associated with CAH-related stroke (OR, 43; 95% CI, 6.8-863; P < .01). CONCLUSIONS The absence of the susceptibility vessel sign was more frequent in CAH-related stroke than in cardioembolism. These findings could potentially be helpful for clinical management and differentiating cardioembolism and CAH-related stroke.
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Affiliation(s)
- Daiki Fukunaga
- From the Department of Neurology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Jun Fujinami
- From the Department of Neurology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Toru Kishitani
- From the Department of Neurology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Naoki Tokuda
- From the Department of Neurology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Soichiro Numa
- From the Department of Neurology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Yoshinari Nagakane
- From the Department of Neurology, Kyoto Second Red Cross Hospital, Kyoto, Japan
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2
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Navi BB, Zhang C, Miller B, Cushman M, Kasner SE, Elkind MSV, Tirschwell DL, Longstreth WT, Kronmal RA, Beyeler M, Elm J, Zweifler RM, Tarsia J, Cereda CW, Bianco G, Costamagna G, Michel P, Broderick JP, Gladstone DJ, Kamel H, Streib C. Apixaban vs Aspirin in Patients With Cancer and Cryptogenic Stroke: A Post Hoc Analysis of the ARCADIA Randomized Clinical Trial. JAMA Neurol 2024; 81:958-965. [PMID: 39133474 PMCID: PMC11320331 DOI: 10.1001/jamaneurol.2024.2404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 06/06/2024] [Indexed: 08/13/2024]
Abstract
Importance Approximately 10% to 15% of ischemic strokes are associated with cancer; cancer-associated stroke, particularly when cryptogenic, is associated with high rates of recurrent stroke and major bleeding. Limited data exist on the safety and efficacy of different antithrombotic strategies in patients with cancer and cryptogenic stroke. Objective To compare apixaban vs aspirin for the prevention of adverse clinical outcomes in patients with history of cancer and cryptogenic stroke. Design, Setting, and Participants Post hoc analysis of data from 1015 patients with a recent cryptogenic stroke and biomarker evidence of atrial cardiopathy in the Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke (ARCADIA) trial, a multicenter, randomized, double-blind clinical trial conducted from 2018 to 2023 at 185 stroke centers in North America. Data analysis was performed from October 15, 2023, to May 23, 2024. Exposures Oral apixaban, 5 mg (or 2.5 mg if criteria met), twice daily vs oral aspirin, 81 mg, once daily. Subgroups of patients with and without cancer at baseline were examined. Main Outcomes and Measures The primary outcome for this post hoc analysis was a composite of major ischemic or major hemorrhagic events. Major ischemic events were recurrent ischemic stroke, myocardial infarction, systemic embolism, and symptomatic deep vein thrombosis or pulmonary embolism. Major hemorrhagic events included symptomatic intracranial hemorrhage and any major extracranial hemorrhage. Results Among 1015 participants (median [IQR] age, 68 [60-76] years; 551 [54.3%] female), 137 (13.5%) had a history of cancer. The median (IQR) follow-up was 1.5 (0.6-2.5) years for patients with history of cancer and 1.5 (0.6-3.0) years for those without history of cancer. Participants with history of cancer, compared with those without history of cancer, had a higher risk of major ischemic or major hemorrhagic events (hazard ratio [HR], 1.73; 95% CI, 1.10-2.71). Among those with history of cancer, 8 of 61 participants (13.1%) randomized to apixaban and 16 of 76 participants (21.1%) randomized to aspirin had a major ischemic or major hemorrhagic event; however, the risk was not significantly different between groups (HR, 0.61; 95% CI, 0.26-1.43). Comparing participants randomized to apixaban vs aspirin among those with cancer, events included recurrent stroke (5 [8.2%] vs 9 [11.8%]), major ischemic events (7 [11.5%] vs 14 [18.4%]), and major hemorrhagic events (1 [1.6%] vs 2 [2.6%]). Conclusions and Relevance Among participants in the ARCADIA trial with history of cancer, the risk of major ischemic and hemorrhagic events did not differ significantly with apixaban compared with aspirin. Trial Registration ClinicalTrials.gov Identifier: NCT03192215.
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Affiliation(s)
- Babak B. Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Benjamin Miller
- Department of Neurology, University of Minnesota, Minneapolis
| | - Mary Cushman
- Division of Hematology and Oncology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington
| | - Scott E. Kasner
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | | | - W. T. Longstreth
- Department of Neurology, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | | | - Morin Beyeler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Jordan Elm
- Department of Biostatistics, Medical University of South Carolina, Charleston
| | | | - Joseph Tarsia
- Ochsner Neuroscience Institute, Ochsner Health, New Orleans, Louisiana
| | - Carlo W. Cereda
- Department of Neurology, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Giovanni Bianco
- Department of Neurology, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Gianluca Costamagna
- Stroke Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Neurology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Patrik Michel
- Department of Clinical Neurosciences, University of Lausanne, Lausanne, Switzerland
| | - Joseph P. Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David J. Gladstone
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, and Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
- Deputy Editor, JAMA Neurology
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3
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Steinauer F, Bücke P, Buffle E, Branca M, Göcmen J, Navi BB, Liberman AL, Boronylo A, Clenin L, Goeldlin M, Lippert J, Volbers B, Meinel TR, Seiffge D, Mujanovic A, Kaesmacher J, Fischer U, Arnold M, Pabst T, Berger MD, Jung S, Beyeler M. Prevalence of right-to-left shunt in stroke patients with cancer. Int J Stroke 2024:17474930241260589. [PMID: 38816936 DOI: 10.1177/17474930241260589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
BACKGROUND AND OBJECTIVES Cancer is associated with an increased risk of acute ischemic stroke (AIS) and venous thromboembolism. The role of a cardiac right-to-left shunt (RLS) as a surrogate parameter for paradoxical embolism in cancer-related strokes is uncertain. We sought to investigate the relationship between the presence of an RLS and cancer in AIS patients. METHODS We included consecutive AIS patients hospitalized at our tertiary stroke center between January 2015 and December 2020 with available RLS status as detected on transesophageal echocardiography (TEE). Active cancers were retrospectively identified and the association with RLS was assessed with multivariable logistic regression and inverse probability of treatment weighting to minimize the ascertainment bias of having a TEE obtained. RESULTS Of the 2236 AIS patients included, 103 (4.6%) had active cancer, of whom 24 (23%) were diagnosed with RLS. An RLS was present in 774 out of the 2133 AIS patients without active cancer (36%). After adjustment and weighting, the absence of RLS was associated with active cancer (adjusted odds ratio (aOR) 2.29; 95% confidence interval (CI), 1.14-4.58). When analysis was restricted to patients younger than 60 years of age or those with a high-risk RLS (Risk of Paradoxical Embolism Score ⩾ 6), there was no association between RLS and cancer (aOR, 3.07; 95% CI, 0.79-11.88 and aOR, 0.56; 95% CI, 0.10-3.10, respectively). CONCLUSION RLS was diagnosed less frequently in AIS patients with cancer than in cancer-free patients, suggesting that arterial sources may play a larger role in cancer-related strokes than paradoxical venous embolization. Future studies are needed to validate these findings and evaluate potential therapeutic implications, such as the general indication, or lack thereof, for patent foramen ovale (PFO) closure in this patient population.
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Affiliation(s)
- Fabienne Steinauer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Eric Buffle
- Department of Cardiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- ARTORG Center, University of Bern, Bern, Switzerland
| | - Mattia Branca
- CTU Bern, Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Jayan Göcmen
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Ava L Liberman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Anna Boronylo
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Leander Clenin
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Martina Goeldlin
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Julian Lippert
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Bastian Volbers
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Adnan Mujanovic
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Neurology Department, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Martin D Berger
- Department of Medical Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
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Kawano T, Mackman N. Cancer patients and ischemic stroke. Thromb Res 2024; 237:155-162. [PMID: 38603819 DOI: 10.1016/j.thromres.2024.03.019] [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: 12/26/2023] [Revised: 02/26/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024]
Abstract
Patients with cancer have an increased risk of ischemic stroke compared to the general population. Additionally, these patients have a worse prognosis compared to stroke patients without cancer. Activation of coagulation appears to play a key role in the pathophysiology of ischemic stroke in patients with cancer. However, the underlying mechanisms remain unknown. Moreover, we do not have a way to identify cancer patients with a high risk of stroke and cannot develop prevention strategies. Therefore, there is an urgent need for neurologists and oncologists to develop screening and prevention strategies for stroke in patients with cancer. In this review, we summarize the characteristics of cancer patients at a high risk of stroke, the predictors for the development of stroke and survival in cancer patients, and possible treatments.
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Affiliation(s)
- Tomohiro Kawano
- Department of Neurology, Kano general hospital, Osaka, Japan
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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5
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Heo JH, Yun J, Kim KH, Jung JW, Yoo J, Kim YD, Nam HS. Cancer-Associated Stroke: Thrombosis Mechanism, Diagnosis, Outcome, and Therapeutic Strategies. J Stroke 2024; 26:164-178. [PMID: 38836266 PMCID: PMC11164583 DOI: 10.5853/jos.2023.03279] [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: 10/04/2023] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 06/06/2024] Open
Abstract
Cancer can induce hypercoagulability, which may lead to stroke. This occurs when tumor cells activate platelets as part of their growth and metastasis. Tumor cells activate platelets by generating thrombin and expressing tissue factor, resulting in tumor cell-induced platelet aggregation. Histopathological studies of thrombi obtained during endovascular thrombectomy in patients with acute stroke and active cancer have shown a high proportion of platelets and thrombin. This underscores the crucial roles of platelets and thrombin in cancer-associated thrombosis. Cancer-associated stroke typically occurs in patients with active cancer and is characterized by distinctive features. These features include multiple infarctions across multiple vascular territories, markedly elevated blood D-dimer levels, and metastasis. The presence of cardiac vegetations on echocardiography is a robust indicator of cancer-associated stroke. Suspicion of cancer-associated stroke during endovascular thrombectomy arises when white thrombi are detected, particularly in patients with active cancer. Cancer-associated stroke is almost certain when histopathological examination of thrombi shows a very high platelet and a very low erythrocyte composition. Patients with cancer-associated stroke have high risks of mortality and recurrent stroke. However, limited data are available on the optimal treatment regimen for stroke prevention in these patients. Thrombosis mechanism in cancer is well understood, and distinct therapeutic targets involving thrombin and platelets have been identified. Therefore, direct thrombin inhibitors and/or antiplatelet agents may effectively prevent stroke recurrence. Additionally, this strategy has potential benefits in cancer treatment as accumulating evidence suggests that aspirin use reduces cancer progression, metastasis, and cancer-related mortality. However, clinical trials are necessary to assess the efficacy of this strategy involving the use of direct thrombin inhibitors and/or antiplatelet therapies.
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Affiliation(s)
- Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, Korea
| | - Jaeseob Yun
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang Hyun Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Wook Jung
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Joonsang Yoo
- Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, Korea
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6
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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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7
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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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8
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Xie W, Hsu S, Lin Y, Xie L, Jin X, Zhu Z, Guo Y, Chen C, Huang D, Boltze J, Li P. Malignancy-associated ischemic stroke: Implications for diagnostic and therapeutic workup. CNS Neurosci Ther 2024; 30:e14619. [PMID: 38532275 PMCID: PMC10965754 DOI: 10.1111/cns.14619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Patients with malignancies have an increased risk of suffering ischemic stroke via several mechanisms such as coagulation dysfunction and other malignancy-related effects as well as iatrogenic causes. Moreover, stroke can be the first sign of an occult malignancy, termed as malignancy-associated ischemic stroke (MAS). Therefore, timely diagnostic assessment and targeted management of this complex clinical situation are critical. FINDINGS Patients with both stroke and malignancy have atypical ages, risk factors, and often exhibit malignancy-related symptoms and multiple lesions on neuroimaging. New biomarkers such as eicosapentaenoic acid and blood mRNA profiles may help in distinguishing MAS from other strokes. In terms of treatment, malignancy should not be considered a contraindication, given comparable rates of recanalization and complications between stroke patients with or without malignancies. CONCLUSION In this review, we summarize the latest developments in diagnosing and managing MAS, especially stroke with occult malignancies, and provide new recommendations from recently emerged clinical evidence for diagnostic and therapeutic workup strategies.
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Affiliation(s)
- Wanqing Xie
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Szuyao Hsu
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yuxuan Lin
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Lv Xie
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Xia Jin
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Ziyu Zhu
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yunlu Guo
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Caiyang Chen
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Dan Huang
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | | | - Peiying Li
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Clinical Research Center, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Outcomes Research ConsortiumClevelandOhioUSA
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Fujinami J, Nagakane Y, Fujikawa K, Murata S, Maezono K, Ohara T, Mizuno T. D-Dimer Trends Predict Recurrent Stroke in Patients with Cancer-Related Hypercoagulability. Cerebrovasc Dis Extra 2023; 14:9-15. [PMID: 38061347 PMCID: PMC10824521 DOI: 10.1159/000535644] [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] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 11/17/2023] [Indexed: 02/01/2024] Open
Abstract
INTRODUCTION In patients with cancer-associated hypercoagulability (CAH)-related stroke, D-dimer trends after anticoagulant therapy may offer a biomarker of treatment efficacy. The purpose of this study was to clarify the association between D-dimer trends and recurrent stroke after anticoagulant therapy in patients with CAH-related stroke. METHODS We performed retrospective cohort study of consecutive patients with CAH-related stroke at two stroke centers from 2011 to 2020. The ratio of posttreatment to pretreatment D-dimer levels (post/pre ratio) was used as an indicator of D-dimer trends after anticoagulant therapy. Fine-Gray models were used to evaluate the association between post/pre ratio and recurrent stroke. RESULTS Among 360 acute ischemic stroke patients with active cancer, 73 patients with CAH-related stroke were included in this study. Recurrent stroke occurred in 13 patients (18%) during a median follow-up time of 28 days (interquartile range, 11-65 days). Multivariate analysis revealed that high post/pre ratio was independently associated with recurrent stroke (per 0.1 increase: hazard ratio 2.20, 95% confidence interval 1.61-3.01, p = 0.012). CONCLUSION D-dimer levels after anticoagulant therapy were associated with recurrent stroke in CAH-related stroke patients. Patients with neutral trends in high D-dimer levels after anticoagulant therapy were at high risk of recurrent stroke.
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Affiliation(s)
- Jun Fujinami
- Department of Neurology, Kyoto Second Red Cross Hospital, Kyoto, Japan,
| | | | - Kei Fujikawa
- Department of Biostatistics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shohei Murata
- Department of Neurology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Keiko Maezono
- Department of Neurology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Tomoyuki Ohara
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshiki Mizuno
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
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10
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Beyeler M, Castigliego P, Baumann J, Ziegler V, Kielkopf M, Mueller M, Bauer-Gambelli SA, Mujanovic A, Meinel TR, Horvath T, Fischer U, Kaesmacher J, Heldner MR, Seiffge D, Arnold M, Pabst T, Berger MD, Navi BB, Jung S, Bücke P. Transient ischemic attacks in patients with active and occult cancer. Front Neurol 2023; 14:1268131. [PMID: 37840935 PMCID: PMC10568457 DOI: 10.3389/fneur.2023.1268131] [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: 07/27/2023] [Accepted: 09/05/2023] [Indexed: 10/17/2023] Open
Abstract
Background and aim Paraneoplastic coagulopathy can present as stroke and is associated with specific biomarker changes. Identifying paraneoplastic coagulopathy can help guide secondary prevention in stroke patients, and early cancer detection might improve outcomes. However, unlike ischemic stroke, it remains unclear whether paraneoplastic coagulopathy is associated with transient ischemic attacks (TIA). This study assessed the presence of cancer-related biomarkers in TIA patients and evaluated long-term mortality rates in patients with and without active cancer. Methods Active cancer was retrospectively identified in consecutive TIA patients treated at a comprehensive stroke center between 2015 and 2019. An association between the presence of cancer and cancer-related biomarkers was assessed using multivariable logistic regression. Long-term mortality after TIA was analyzed using multivariable Cox regression. Results Among 1436 TIA patients, 72 had active cancer (5%), of which 17 were occult (1.2%). Cancer-related TIA was associated with male gender (adjusted odds ratio [aOR] 2.29, 95% CI 1.12-4.68), history of smoking (aOR 2.77, 95% CI 1.34-5.7), elevated D-dimer (aOR 1.77, 95% CI 1.26-2.49), lactate dehydrogenase (aOR 1.003, 95% CI 1.00-1.005), lower leukocyte count (aOR 1.20, 95% CI 1.04-1.38), and lower hemoglobin (aOR 1.02, 95% CI 1.00-1.04). Long-term mortality was associated with both active cancer (adjusted hazard ratios [aHR] 2.47, 95% CI 1.58-3.88) and occult cancer (aHR 3.08, 95% CI 1.30-7.32). Conclusion Cancer-related TIA is not uncommon. Biomarkers known to be associated with cancer-related stroke also seem to be present in TIA patients. Early identification would enable targeted treatment strategies and could improve outcomes in this patient population.
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Affiliation(s)
- Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Pasquale Castigliego
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joel Baumann
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Victor Ziegler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Kielkopf
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Madlaine Mueller
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan A. Bauer-Gambelli
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adnan Mujanovic
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Raphael Meinel
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Horvath
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Neurology Department, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Martin D. Berger
- Department of Medical Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Babak B. Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, United States
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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11
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Zúñiga GA, Kandula P, Sandefur H, Tafur AJ. A Patient with Recurrent Strokes: Approach to Coagulopathy. TH OPEN 2023; 7:e262-e269. [PMID: 37772086 PMCID: PMC10533221 DOI: 10.1055/a-2161-1262] [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: 04/06/2023] [Accepted: 08/15/2023] [Indexed: 09/30/2023] Open
Abstract
Despite anticoagulation recommendations, patients may present with recurrent events. While medication adherence is always a concern, assessment of anticoagulation failure demands a systematic approach, taking into account the potential limitations of anticoagulants and a review of differential diagnoses for comorbidities. We illustrate our approach in a case presentation.
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Affiliation(s)
| | - Pranav Kandula
- Division of Cardiology, NorthShore University HealthSystem, Evanston, Illinois, United States
- College of Engineering, Ohio State University, Columbus, Ohio, United States
| | - Hardy Sandefur
- Division of Cardiology, NorthShore University HealthSystem, Evanston, Illinois, United States
| | - Alfonso J. Tafur
- Division of Cardiology, NorthShore University HealthSystem, Evanston, Illinois, United States
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12
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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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13
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Beyeler M, Belachew NF, Kielkopf M, Aleman EB, León Betancourt AX, Genceviciute K, Kurmann C, Grunder L, Birner B, Meinel TR, Scutelnic A, Bücke P, Seiffge DJ, Dobrocky T, Piechowiak EI, Pilgram-Pastor S, Mattle HP, Mordasini P, Arnold M, Fischer U, Pabst T, Gralla J, Berger MD, Jung S, Kaesmacher J. Absence of Susceptibility Vessel Sign in Patients With Malignancy-Related Acute Ischemic Stroke Treated With Mechanical Thrombectomy. Front Neurol 2022; 13:930635. [PMID: 35911907 PMCID: PMC9331190 DOI: 10.3389/fneur.2022.930635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose Clots rich in platelets and fibrin retrieved from patients with acute ischemic stroke (AIS) have been shown to be independently associated with the absence of the susceptibility vessel sign (SVS) on MRI and active malignancy. This study analyzed the association of SVS and the presence of active malignancy in patients with AIS who underwent mechanical thrombectomy (MT). Methods This single-center, retrospective, and cross-sectional study included consecutive patients with AIS with admission MRI treated with MT between January 2010 and December 2018. SVS status was evaluated on susceptibility-weighted imaging. Adjusted odds ratios (aORs) were calculated to determine the association between absent SVS and the presence of active or occult malignancy. The performance of predictive models incorporating and excluding SVS status was compared using areas under the receiver operating characteristics curve (auROC). Results Of 577 patients with AIS with assessable SVS status, 40 (6.9%) had a documented active malignancy and 72 (12.5%) showed no SVS. The absence of SVS was associated with active malignancy (aOR 4.85, 95% CI 1.94–12.11) or occult malignancy (aOR 11.42, 95% CI 2.36–55.20). The auROC of predictive models, including demographics and common malignancy biomarkers, was higher but not significant (0.85 vs. 0.81, p = 0.07) when SVS status was included. Conclusion Absence of SVS on admission MRI of patients with AIS undergoing MT is associated with malignancy, regardless of whether known or occult. Therefore, the SVS might be helpful in detecting paraneoplastic coagulation disorders and occult malignancy in patients with AIS.
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Affiliation(s)
- Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- *Correspondence: Morin Beyeler
| | - Nebiyat F. Belachew
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neuroradiology, Faculty of Medicine, Medical Center – University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Moritz Kielkopf
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Enrique B. Aleman
- Department of Neuroradiology, Faculty of Medicine, Medical Center – University of Freiburg, University of Freiburg, Freiburg, Germany
| | | | - Kotryna Genceviciute
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Kurmann
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Grunder
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Barbara Birner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas R. Meinel
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David J. Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Eike I. Piechowiak
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sara Pilgram-Pastor
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heinrich P. Mattle
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin D. Berger
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Johannes Kaesmacher
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14
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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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15
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Nakajima S, Kawano H, Yamashiro K, Tanaka R, Kameda T, Kurita N, Hira K, Miyamoto N, Ueno Y, Watanabe M, Hirano T, Fujimoto S, Urabe T, Hattori N. Post-Treatment Plasma D-Dimer Levels Are Associated With Short-Term Outcomes in Patients With Cancer-Associated Stroke. Front Neurol 2022; 13:868137. [PMID: 35444612 PMCID: PMC9015657 DOI: 10.3389/fneur.2022.868137] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/17/2022] [Indexed: 12/21/2022] Open
Abstract
Background and Objective Hypercoagulability is associated with increased risks of ischemic stroke and subsequent mortality in patients with active cancer. This study investigated the relationships between plasma D-dimer levels after stroke treatment and short-term outcomes in patients with cancer-associated stroke. Methods This retrospective, observational, multicenter study analyzed consecutive patients with cancer-associated ischemic stroke. Hypercoagulability was assessed by plasma D-dimer levels before and after stroke treatment. Short-term outcomes were assessed in terms of poor outcomes (a modified Rankin Scale score >3), cumulative rates of recurrent ischemic stroke, and mortality at 30 days after admission. Results Of 282 patients, 135 (47.9%) showed poor outcomes. Recurrent ischemic stroke was observed in 28 patients (9.9%), and the cumulative mortality rate was 12.4%. Multivariate analysis showed that post-treatment plasma D-dimer levels ≥10 μg/ml were independently associated with both poor outcomes (adjusted odds ratio [OR], 9.61; 95% confidence interval [CI], 3.60–25.70; P < 0.001) and mortality (adjusted OR, 9.38; 95% CI, 3.32–26.44; P < 0.001). Pre-treatment plasma D-dimer levels ≥10 μg/ml were not associated with these outcomes. Patients who received heparin had higher pre-treatment plasma D-dimer levels than those treated with other anticoagulants. Heparin produced a significant reduction in D-dimer levels from pre- to post-treatment without increasing the incidence of hemorrhagic events. Conclusion A high plasma D-dimer level after stroke treatment was associated with poor short-term outcomes in patients with cancer-associated stroke. Using anticoagulants to reduce D-dimer levels may improve short-term outcomes in these patients.
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Affiliation(s)
- Sho Nakajima
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan.,Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Hiroyuki Kawano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
| | - Kazuo Yamashiro
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan.,Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Ryota Tanaka
- Division of Neurology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Tomoaki Kameda
- Department of Neurology, Shin-Oyama City Hospital, Tochigi, Japan
| | - Naohide Kurita
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan.,Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Kenichiro Hira
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Nobukazu Miyamoto
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuji Ueno
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Masao Watanabe
- Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
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16
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Mattingly TK, Risco JE, Burch JE, Whyte R, Kohli GS, Susa S, Bhalla T, Bender MT. Endovascular Therapy is Effective for Large Vessel Occlusion Despite Concurrent Cancer. J Stroke Cerebrovasc Dis 2022; 31:106439. [PMID: 35313233 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106439] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/19/2022] [Accepted: 02/23/2022] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Ischemic stroke and concurrent cancer is increasingly recognized. However, optimal management is uncertain. As mechanical thrombectomy has become the standard of care for large vessel occlusion, more patients with cancer are presenting for embolectomy. However, it is unknown whether this subgroup has the same benefit profile described in multiple randomized trials for thrombectomy for large vessel occlusion. Our objective was to retrospectively evaluate a North American embolectomy database for safety and outcomes in patients with active cancer. MATERIALS AND METHODS A case series of 284 embolectomies over 30 months at a single North American stroke center were divided into thrombectomy patients with active cancer(n=25) and those without active cancer (n=259). We compared patient characteristics, procedural characteristics, and procedural outcomes between patients with and without active cancer. Univariate and multivariate analysis of angiographic outcomes, postoperative hemorrhage, and functional outcome was performed. RESULTS Of the 284 thrombectomy cases, 9% were performed on patients with active cancer. Active cancer patients had a similar recanalization grade and post-operative hemorrhage rate, compared to patients without cancer. Active cancer patients had a significantly higher 90 day mortality (40% vs 20%, p=0.018). On multivariate analysis, good functional outcome (mRS 0-2) was not impacted by active cancer. However, when mRS was evaluated as an ordinal shift analysis, worse functional outcome was associated with active cancer (OR 2.98; 95% CI, 1.29 to 6.59), greater age, NIHSS> 10, and ASPECTS<9. CONCLUSIONS This single center retrospective series of active cancer patients undergoing thrombectomy for large vessel occlusion demonstrates similar rates of recanalization, post-operative hemorrhage, and good outcomes. While the active cancer group has a high short-term mortality, the potential to maintain quality of life in the survivors makes thrombectomy reasonable in this patient population. Awareness of ischemic stroke as a complication of cancer and the safety of thrombectomy in this population are important as this population subtype is expected to grow with improved oncology and stroke care.
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Affiliation(s)
- Thomas K Mattingly
- Dept of Neurosurgery, University of Rochester, Rochester, NY. 585-273-1900, United States.
| | - Jorge E Risco
- Dept of Neurology, University of Rochester, Rochester, NY. 585-275-2776, United States
| | - Jaclyn E Burch
- Dept of Neurology, University of Rochester, Rochester, NY. 585-275-2776, United States
| | - Raquel Whyte
- Dept of Neurosurgery, University of Rochester, Rochester, NY. 585-273-1900, United States
| | - Gurkirat S Kohli
- Dept of Neurosurgery, University of Rochester, Rochester, NY. 585-273-1900, United States
| | - Stephen Susa
- Dept of Neurosurgery, University of Rochester, Rochester, NY. 585-273-1900, United States
| | - Tarun Bhalla
- Dept of Neurosurgery, University of Rochester, Rochester, NY. 585-273-1900, United States
| | - Matthew T Bender
- Dept of Neurosurgery, University of Rochester, Rochester, NY. 585-273-1900, United States
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17
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Yamaura G, Ito T, Miyaji Y, Ueda N, Nakae Y, Momoo T, Nakano T, Johmura Y, Higashiyama Y, Joki H, Doi H, Takeuchi H, Takahashi T, Koyano S, Yamaguchi S, Yokoyama M, Tanaka F. Therapeutic efficacy of heparin and direct factor Xa inhibitors in cancer-associated cryptogenic ischemic stroke with venous thromboembolism. Thromb Res 2021; 206:99-103. [PMID: 34454242 DOI: 10.1016/j.thromres.2021.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Anticoagulation therapy, especially using heparin or recently developed oral direct factor Xa inhibitors (DiXals), is recommended as first-line treatment for cancer-related venous thromboembolism (VTE). However, the preventive efficacy of these anticoagulants for cancer-associated ischemic stroke is still unknown. We retrospectively investigated the efficacy of subcutaneous unfractionated heparin (UFH) and DiXals for preventing the recurrence of cancer-associated cryptogenic ischemic stroke with VTE. METHODS We retrospectively studied consecutive patients with cancer-associated cryptogenic ischemic stroke and comorbid VTE who received subcutaneous UFH or oral DiXaIs at 9 hospitals. RESULT Fifty-three patients (24 treated with UFH and 29 treated with DiXaIs) were enrolled. Of these, 47 demonstrated systemic metastasis (cancer stage IV). During 30-day follow-up after initiation of anticoagulation therapy, recurrent ischemic stroke was observed in only 1 patient (4%) in the UFH group and in 9 patients (31%) in the DiXal group. The incidence of major bleeding complications was similar between the 2 groups (4% and 10%, respectively). The cumulative risk of ischemic stroke recurrence within 30 days was lower with UFH than with DiXals (competing risk analysis, p = 0.008). In the DiXal group, patients who experienced recurrence showed significantly higher D-dimer levels than those without recurrence. CONCLUSION In patients with cancer-associated cryptogenic ischemic stroke and comorbid VTE, UFH demonstrated a lower rate of recurrent ischemic stroke than DiXaIs, and there were no differences in bleeding risk between the 2 treatments. D-dimer levels at stroke onset increased the risk of recurrence in the DiXal group but not in the UFH group.
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Affiliation(s)
- Genpei Yamaura
- Department of Neurology, Fujisawa City Hospital, 2-6-1 Fujisawa, Fujisawa 251-8550, Japan
| | - Takeshi Ito
- Department of Neurology, Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawanishimachi, Kanagawa-ku, Yokohama 221-0855, Japan
| | - Yosuke Miyaji
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Naohisa Ueda
- Department of Neurology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Yoshiharu Nakae
- Department of Neurology, Saiseikai Yokohamashi Nanbu Hospital, 3-2-10 Konandai, Konan-ku, Yokohama 234-0054, Japan
| | - Takayuki Momoo
- Department of Neurology, Hiratsuka Kyosai Hospital, 9-11 Oiwake, Hiratsuka 254-8502, Japan
| | - Tatsu Nakano
- Department of Neurology and Stroke Medicine, Yokohama Sakae Kyosai Hospital, 132 Katsura-cho, Sakae-ku, Yokohama 247-8581, Japan
| | - Yuji Johmura
- Department of Neurology, Yokohama Minami Kyousai Hospital, 1-21-1 Mutsuurahigashi, Kanazawa-ku, Yokohama 236-0037, Japan
| | - Yuichi Higashiyama
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Hideto Joki
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Hiroshi Doi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Hideyuki Takeuchi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Tatsuya Takahashi
- Department of Neurology, National Hospital Organization Yokohama Medical Center, 3-60-2 Harajuku, Totsuka-ku, Yokohama 245-8575, Japan
| | - Shigeru Koyano
- Department of Neurology, Yokohama Minami Kyousai Hospital, 1-21-1 Mutsuurahigashi, Kanazawa-ku, Yokohama 236-0037, Japan
| | - Shigeki Yamaguchi
- Department of Neurology, Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawanishimachi, Kanagawa-ku, Yokohama 221-0855, Japan
| | - Mutsumi Yokoyama
- Department of Neurology, Fujisawa City Hospital, 2-6-1 Fujisawa, Fujisawa 251-8550, Japan
| | - Fumiaki Tanaka
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
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18
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Wang Z, Miao J, Wang L, Liu Y, Ji H, Zhang X, Cui L. EGFR-mutant NSCLC presenting with stroke and massive systemic embolization as the first manifestation: case report. BMC Neurol 2021; 21:221. [PMID: 34107910 PMCID: PMC8188717 DOI: 10.1186/s12883-021-02236-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/11/2021] [Indexed: 12/21/2022] Open
Abstract
Background Presentation with massive systemic embolization as the initial manifestation of occult malignancy is infrequent. The standard management of cancer-related arterial thromboembolism has not yet been established. Case presentation We described a case of Trousseau’s syndrome resulting in acute ischemic stroke concomitant with multiple embolizations in the spleen and kidney during oral administration of dabigatran for pulmonary embolism preceding the diagnosis of a malignant tumor. A cancer-related hypercoagulable state was suspected because the patient was admitted to the neurology department due to acute ischemic stroke with three territory infarcts on diffusion-weighted imaging (DWI) in the absence of identifiable conventional risk factors and brain vessel narrowing. The patient was subsequently diagnosed with epidermal growth factor receptor (EGFR) mutation–positive non-small-cell lung cancer (NSCLC) (stage IV) with pleural metastasis. Administration of low-molecular-weight heparin followed by long-term dabigatran under effective cancer therapy comprising gefitinib and subsequent chemotherapy did not cause stroke relapse during the 1-year follow-up. Conclusions This case suggests that cancer-related hypercoagulability should be considered an important etiology for stroke patients who develop unexplained disseminated acute cerebral infarction without conventional stroke risk factors, especially concomitant with multiple organ embolization. Novel oral anticoagulants may be an alternative therapy for the long-term management of cancer-related arterial thromboembolism under effective cancer therapy.
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Affiliation(s)
- Zheng Wang
- Department of Respiratory Medicine III, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jiangyong Miao
- Department of Neurology, The Second Hospital of Hebei Medical University, 309 Zhonghuabei Street, Hebei, 050000, Shijiazhuang, People's Republic of China.,Hebei Key Laboratory of Vascular Homeostasis and Hebei Collaborative Innovation Center for Cardio-cerebrovascular Disease, Shijiazhuang, Hebei, China
| | - Lina Wang
- Department of Neurology, The Second Hospital of Hebei Medical University, 309 Zhonghuabei Street, Hebei, 050000, Shijiazhuang, People's Republic of China
| | - Ying Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, 309 Zhonghuabei Street, Hebei, 050000, Shijiazhuang, People's Republic of China
| | - Hui Ji
- Department of Neurology, The Second Hospital of Hebei Medical University, 309 Zhonghuabei Street, Hebei, 050000, Shijiazhuang, People's Republic of China
| | - Xiangjian Zhang
- Department of Neurology, The Second Hospital of Hebei Medical University, 309 Zhonghuabei Street, Hebei, 050000, Shijiazhuang, People's Republic of China.,Hebei Key Laboratory of Vascular Homeostasis and Hebei Collaborative Innovation Center for Cardio-cerebrovascular Disease, Shijiazhuang, Hebei, China
| | - Lili Cui
- Department of Neurology, The Second Hospital of Hebei Medical University, 309 Zhonghuabei Street, Hebei, 050000, Shijiazhuang, People's Republic of China. .,Hebei Key Laboratory of Vascular Homeostasis and Hebei Collaborative Innovation Center for Cardio-cerebrovascular Disease, Shijiazhuang, Hebei, China.
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19
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Wu S, Xing Z, Lin J, Liu H, Cui F, Xu R. Clinical practice: intravenous thrombolysis in a patient with active cancer who experienced wake-up stroke. J Int Med Res 2021; 49:3000605211000155. [PMID: 33719669 PMCID: PMC7960903 DOI: 10.1177/03000605211000155] [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] [Indexed: 11/25/2022] Open
Abstract
After reviewing the diagnosis and treatment process of a patient with active cancer who experienced wake-up stroke, we have summarized the clinical manifestations, laboratory examination results, imaging features, pathological results, and treatment in this report. Patients with active cancer who experience wake-up stroke often have mild neurological deficits at the time of onset. For the patient in this study, laboratory test results were mainly characterized by abnormal coagulation function and elevated tumor markers. The brain magnetic resonance imaging (MRI) images were characterized by involvement of both the arterial and venous systems. Thrombolytic therapy during the window period can improve the symptoms of neurological deficits. Overall, anticoagulation therapy was safe and effective in our patient.
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Affiliation(s)
- Siting Wu
- Department of Neurology, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Zengluan Xing
- Department of Neurology, Cadre Sanatorium of Hainan (Geriatric Hospital of Hainan), Haikou, China
| | - Jiacai Lin
- Department of Neurology, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Hui Liu
- Department of Oncology, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Fang Cui
- Department of Neurology, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Rui Xu
- Department of Oncology, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
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20
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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: 26] [Impact Index Per Article: 6.5] [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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21
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Multiple Thrombectomies in the Same Patient within One Month: Case Report of a Patient with Trousseau Syndrome and Acute Ischemic Stroke. Brain Sci 2020; 10:brainsci10090590. [PMID: 32858908 PMCID: PMC7565654 DOI: 10.3390/brainsci10090590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 07/30/2020] [Accepted: 08/24/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Since Trousseau's initial publication, the development of thromboembolic events related to malignancy has been well established. The pathophysiology of this is understood to be through activation of the coagulation cascade through neoplastic cells themselves or the therapy initiated (chemotherapy or surgery). To date, there have been a variety of studies, such as the OASIS-CANCER trial, which highlight the relationship of hypercoagulability to ischemic stroke. Despite these efforts, clear evidence is lacking for the utilization of antiplatelet or anticoagulation therapy in the secondary prevention of stroke following mechanical thrombectomy in patients with suspected or confirmed malignancy. CLINICAL PRESENTATION A 71-year-old female with a history of immune thrombocytopenia, diabetes mellitus, and hypertension who was undergoing an evaluation for a lung nodule, later determined to be adenocarcinoma of the lung, underwent three successful mechanical thrombectomies for acute ischemic stroke with large vessel occlusion over a one month period. This patient had improved National Institutes of Health Stroke Scale (NIHSS) scores following each of her thrombectomies. However, her history of immune thrombocytopenia and underlying malignancy complicated her discharge medication regimen following each of her thrombectomies and may have contributed to her repeat strokes. CONCLUSION Clear guidance is lacking regarding the utilization of antiplatelet and anticoagulation therapy in patients with suspected or confirmed malignancy following mechanical thrombectomy. Review of the literature suggests that controlling a patient's hypercoagulability may lead to improved clinical outcomes, but further clinical trials are warranted.
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22
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Wassef C, Grenga A, Goldman B, Mattingly T. Triple Thrombectomy for Trousseau Syndrome: Case Report and Review of the Literature of Stroke Intervention in Cancer-associated Thrombus. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:301-306. [PMID: 37502176 PMCID: PMC10370598 DOI: 10.5797/jnet.cr.2019-0111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/08/2020] [Indexed: 07/29/2023]
Abstract
Objective There are few papers regarding repeat mechanical thrombectomy or thrombectomy for Trousseau's related stroke. We present a unique case of repeat thrombectomy due to Trousseau's syndrome affecting the same vessel in a patient with metastatic cancer. Case Presentation A 47-year-old male presented with a full left middle cerebral artery syndrome and a National Institute of Health Stroke Scale of 17, despite regular apixaban use. He underwent mechanical thrombectomy successfully but developed recurrent symptoms on postoperative day (POD) 6 while on warfarin. He underwent two additional thrombectomies, the final one requiring glycoprotein IIa/IIIb inhibitor for emergent implantation of intracranial stent. Successful recanalization (thrombolysis in cerebral infarction 2b) was achieved, and the patient was discharged home on dual antiplatelet therapy and enoxaparin on POD 10 after last thrombectomy, ambulatory and independent in his activities of daily living. The patient expired as a result of his metastatic disease 109 days after the third procedure and was ambulatory for 91 of those days. Conclusion This case illustrates the palliative aspects of mechanical thrombectomy and the complexities of anticoagulation management in patients with the metastatic disease Trousseau's syndrome.
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Affiliation(s)
- Catherine Wassef
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Audrey Grenga
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Bruce Goldman
- Department of Pathology, University of Rochester Medical Center, Rochester, NY, USA
| | - Thomas Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
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23
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Martinez-Majander N, Ntaios G, Liu YY, Ylikotila P, Joensuu H, Saarinen J, Perera KS, Marti-Fabregas J, Chamorro A, Rudilosso S, Prats-Sanchez L, Berkowitz SD, Mundl H, Themeles E, Tiainen M, Demchuk A, Kasner SE, Hart RG, Tatlisumak T. Rivaroxaban versus aspirin for secondary prevention of ischaemic stroke in patients with cancer: a subgroup analysis of the NAVIGATE ESUS randomized trial. Eur J Neurol 2020; 27:841-848. [PMID: 32056346 DOI: 10.1111/ene.14172] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 02/08/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Cancer is a frequent finding in ischaemic stroke patients. The frequency of cancer amongst participants in the NAVIGATE ESUS randomized trial and the distribution of outcome events during treatment with aspirin and rivaroxaban were investigated. METHODS Trial participation required a recent embolic stroke of undetermined source. Patients' history of cancer was recorded at the time of study entry. During a mean follow-up of 11 months, the effects of aspirin and rivaroxaban treatment on recurrent ischaemic stroke, major bleeding and all-cause mortality were compared between patients with cancer and patients without cancer. RESULTS Amongst 7213 randomized patients, 543 (7.5%) had cancer. Of all patients, 3609 were randomized to rivaroxaban [254 (7.0%) with cancer] and 3604 patients to aspirin [289 (8.0%) with cancer]. The annual rate of recurrent ischaemic stroke was 4.5% in non-cancer patients in the rivaroxaban arm and 4.6% in the aspirin arm [hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.78-1.24]. In cancer patients, the rate of recurrent ischaemic stroke was 7.7% in the rivaroxaban arm and 5.4% in the aspirin arm (HR 1.43, 95% CI 0.71-2.87). Amongst cancer patients, the annual rate of major bleeds was non-significantly higher for rivaroxaban than aspirin (2.9% vs. 1.1%; HR 2.57, 95% CI 0.67-9.96; P for interaction 0.95). All-cause mortality was similar in both groups. CONCLUSIONS Our exploratory analyses show that patients with embolic stroke of undetermined source and a history of cancer had similar rates of recurrent ischaemic strokes and all-cause mortality during aspirin and rivaroxaban treatments and that aspirin appeared safer than rivaroxaban in cancer patients regarding major bleeds. www.clinicaltrials.gov (NCT02313909).
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Affiliation(s)
- N Martinez-Majander
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - G Ntaios
- Department of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Y Y Liu
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - P Ylikotila
- Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland
| | - H Joensuu
- Department of Oncology, Helsinki University Hospital, Helsinki, Finland
| | - J Saarinen
- Department of Neurology, Vaasa Central Hospital, Vaasa, Finland
| | - K S Perera
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - J Marti-Fabregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain
| | - A Chamorro
- Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, Spain
| | - S Rudilosso
- Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, Spain
| | - L Prats-Sanchez
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain
| | | | - H Mundl
- Bayer Pharma AG, Wuppertal, Germany
| | - E Themeles
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - M Tiainen
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - A Demchuk
- Calgary Stroke Program, Departments of Clinical Neuroscience and Radiology and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - S E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - R G Hart
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - T Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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24
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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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25
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Ohara T, Farhoudi M, Bang OY, Koga M, Demchuk AM. The emerging value of serum D-dimer measurement in the work-up and management of ischemic stroke. Int J Stroke 2019; 15:122-131. [DOI: 10.1177/1747493019876538] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Elevated D-dimer levels are a marker of both thrombin formation and fibrinolysis. Currently D-dimer measurement is routinely used for ruling out venous thromboembolism and diagnosis/monitoring of disseminated intravascular coagulation. Recent emerging data suggest that D-dimer may become an important biomarker in ischemic stroke as well as in cardiovascular diseases. Aims To outline the clinical utility of D-dimer in work-up and management of ischemic stroke. Summary D-dimer measurement is most useful in stroke with active cancer as it can confirm etiologic diagnosis, predict recurrent stroke risk, and aid treatment decision in cancer-associated stroke. In cryptogenic stroke, high D-dimer levels can also provide clues for the cause of stroke as occult cancer and undetected cardiac embolic source as occult atrial fibrillation and may be helpful in treatment decision making of secondary stroke prevention. Serial D-dimer measurements should be further studied to monitor antithrombotic therapy effectiveness in both cardiogenic and cryptogenic etiologies. Conclusion Accumulating data suggests the utility of D-dimer test in the management of ischemic stroke, although the evidence is still limited. Future studies would clarify the role of D-dimer measurement in ischemic stroke.
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Affiliation(s)
- Tomoyuki Ohara
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine University of Calgary, Calgary, Canada
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Mehdi Farhoudi
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine University of Calgary, Calgary, Canada
- Neurosciences Research Center, Neurology Department, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Andrew M Demchuk
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine University of Calgary, Calgary, Canada
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26
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Abstract
Patients with cancer-associated ischemic stroke pose similar clinical manifestations and image characteristics, mainly embolic infarction, as patients with atrial fibrillation do. D-dimer, a degraded product of fibrin polymer, is a useful indicator of hypercoagulability, which frequently increases in cancer-associated stroke, but not in stroke resulted from atrial fibrillation. The level of serum D-dimer is associated with mortality, prognosis, and recurrence of systemic thromboembolism in these patients. Theoretically, drugs block coagulation cascade, such as heparin and low-molecular-weight-heparin (LMWH), oral direct anticoagulants, could attenuate the status of hypercoagulation and decrease the amount of D-dimer. These drugs may be helpful to prevent thromboembolic events in patients with cancer-associated hypercoagulability. Vitamin K antagonist, warfarin, decreases the production of coagulation factors, but not interrupts coagulation cascade may not be helpful to decrease hypercoagulability, but increase the risk of bleeding. However, the treatment of cancer-associated embolic stroke is still controversial. This article reviews relevant clinical studies and proposes the applicability of direct oral anticoagulants from the pathophysiological mechanism.
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Affiliation(s)
- Jin-Yi Hsu
- Department of Neurology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - An-Bang Liu
- Department of Neurology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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27
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Navi BB, Iadecola C. Ischemic stroke in cancer patients: A review of an underappreciated pathology. Ann Neurol 2018; 83:873-883. [PMID: 29633334 PMCID: PMC6021225 DOI: 10.1002/ana.25227] [Citation(s) in RCA: 159] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 04/02/2018] [Accepted: 04/02/2018] [Indexed: 02/06/2023]
Abstract
Currently 1 in 10 patients with ischemic stroke have comorbid cancer, and this frequency is expected to increase with continued advances in cancer therapeutics prolonging median survival. Well known for its association with venous thrombosis, cancer has recently emerged as a significant risk factor for arterial thromboembolism, including stroke; however, the underlying mechanisms are uncertain. In addition, the optimal strategies to prevent and acutely treat stroke in cancer patients are yet to be established. This review summarizes the current evidence on ischemic stroke risk, biomarkers, pathophysiology, treatments, and prognosis in cancer patients, emphasizing knowledge gaps and the potential strategies to address them. Ann Neurol 2018;83:873-883.
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Affiliation(s)
- Babak B Navi
- Department of Neurology
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Costantino Iadecola
- Department of Neurology
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
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Wang L, Xu Y, Tuo M, Zhang L, Zhang H, Wang J. Recurrent stroke in a patient of lung cancer without pulmonary mass: A case report. Medicine (Baltimore) 2018; 97:e9815. [PMID: 29384885 PMCID: PMC5805457 DOI: 10.1097/md.0000000000009815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Repeated occurring stroke in short intervals with hypercoagulability is unusual so in such cases the conventional vascular risk factors might not be the causes of stroke. PATIENT CONCERNS We have presented a case of 60-year-old male presenting with recurrent stroke due to thrombophilia. DIAGNOSES Lung cancer was detected by superficial lymph nodes ultrasound and further pathological examination. INTERVENTIONS The patient suffered a recurrent stroke and he had persistently high level of D-dimer which suggested the diagnosis of thrombophilia, thus, he was treated with low-molecular-weight heparin. Unfortunately, the treatment was not effective for the patient and he died before any other treatments could be administered. OUTCOMES Despite anticoagulant therapy, the patient suffered multiple episodes of stroke and ultimately died. LESSONS This case of recurrent stroke with coagulation disorders without evidence of cancer in imaging and blood test is rare. So in a stroke patient, we should consider malignancy or metastasis as a differential diagnosis as it may be the first manifestation of active cancer elsewhere.
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Suero-Abreu GA, Cheng JZ, Then RK. Multiple recurrent ischaemic strokes in a patient with cancer: is there a role for the initiation of anticoagulation therapy for secondary stroke prevention? BMJ Case Rep 2017; 2017:bcr-2016-218105. [PMID: 28578306 PMCID: PMC5534754 DOI: 10.1136/bcr-2016-218105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
A 52-year-old woman with a medical history of cervical and thyroid cancer, hypertension, dyslipidaemia, uncontrolled diabetes and heavy smoking was diagnosed with a new metastatic cholangiocarcinoma. While undergoing palliative chemotherapy, she developed dysarthria and left-sided weakness. Imaging studies showed multiple bilateral ischaemic strokes. On hospital days 2 and 5, she developed worsening neurological symptoms and imaging studies revealed new areas of ischaemia on respective days. Subsequent workup did not revealed a clear aetiology for the multiple ischaemic events and hypercoagulability studies were only significant for a mildly elevated serum D-dimer level. Although guidelines are unclear, full-dose anticoagulation with low molecular weight heparin was initiated given her high risk of stroke recurrence. She was discharged to acute rehabilitation but, within a month, she experienced complications of her malignant disease progression and a new pulmonary thromboembolism. The patient died soon after being discharged home with hospice care.
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Affiliation(s)
- Giselle Alexandra Suero-Abreu
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, New Jersey, USA.,Department of Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Jia Zhen Cheng
- Department of Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Ryna Karina Then
- Department of Neurology, Cooper University Hospital, Camden, New Jersey, USA
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30
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Takasugi J, Sakaguchi M, Oyama N, Gon Y, Terasaki Y, Sasaki T, Nakahara S, Ohshima K, Hori Y, Morii E, Mochizuki H. Recurrent Stroke Due to Metastatic Pulmonary Tumor Emboli as an Important Clinical Entity. J Stroke Cerebrovasc Dis 2017; 26:e108-e110. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 02/26/2017] [Accepted: 03/08/2017] [Indexed: 12/21/2022] Open
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31
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Lee MJ, Chung JW, Ahn MJ, Kim S, Seok JM, Jang HM, Kim GM, Chung CS, Lee KH, Bang OY. Hypercoagulability and Mortality of Patients with Stroke and Active Cancer: The OASIS-CANCER Study. J Stroke 2016; 19:77-87. [PMID: 28030894 PMCID: PMC5307941 DOI: 10.5853/jos.2016.00570] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/25/2016] [Accepted: 10/04/2016] [Indexed: 12/28/2022] Open
Abstract
Background and Purpose Patients with active cancer are at an increased risk for stroke. Hypercoagulability plays an important role in cancer-related stroke. We aimed to test whether 1) hypercoagulability is a predictor of survival, and 2) correction of the hypercoagulable state leads to better survival in patients with stroke and active cancer. Methods We recruited consecutive patients with acute ischemic stroke and active systemic cancer between January 2006 and July 2015. Hypercoagulability was assessed using plasma D-dimer levels before and after 7 days of anticoagulation treatment. The study outcomes included overall and 1-year survival. Plasma D-dimer levels before and after treatment were tested in univariate and multivariate Cox regression models. We controlled for systemic metastasis, stroke mechanism, age, stroke severity, primary cancer type, histology, and atrial fibrillation using the forward stepwise method. Results A total of 268 patients were included in the analysis. Patients with high (3rd–4th quartiles) pre-treatment plasma D-dimer levels showed decreased overall and 1-year survival (adjusted HR, 2.19 [95% CI, 1.46–3.31] and 2.70 [1.68–4.35], respectively). After anticoagulation treatment, post-treatment D-dimer level was significantly reduced and independently associated with poor 1-year survival (adjusted HR, 1.03 [95% CI, 1.01–1.05] per 1 μg/mL increase, P=0.015). The successful correction of hypercoagulability was a protective factor for 1-year survival (adjusted HR 0.26 [CI 0.10–0.68], P=0.006). Conclusions Hypercoagulability is associated with poor survival after stroke in patients with active cancer. Effective correction of hypercoagulability may play a protective role for survival in these patients.
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Affiliation(s)
- Mi Ji Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung-Ju Ahn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seonwoo Kim
- Biostatistics Team, Samsung Biomedical Research Institute, Samsung Medical Center, Seoul, Korea
| | - Jin Myoung Seok
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Min Jang
- 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
| | - Chin-Sang Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Ho Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Interleukin 37 (IL-37) is a new member of the IL-1 family which all have a similar β-barrel structure. Since its discovery, IL-37 has been studied extensively in immunological field. It has been established that IL-37 possesses anti-inflammatory characteristics both in innate immune response as well as in acquired immune responses by downregulating pro-inflammatory molecules. This review will discuss the role of IL-37 in immunological processes and neoplastic pathogenesis.
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Nouh A, Hussain M, Mehta T, Yaghi S. Embolic Strokes of Unknown Source and Cryptogenic Stroke: Implications in Clinical Practice. Front Neurol 2016; 7:37. [PMID: 27047443 PMCID: PMC4800279 DOI: 10.3389/fneur.2016.00037] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/07/2016] [Indexed: 12/31/2022] Open
Abstract
Up to a third of strokes are rendered cryptogenic or of undetermined etiology. This number is specifically higher in younger patients. At times, inadequate diagnostic workups, multiple causes, or an under-recognized etiology contributes to this statistic. Embolic stroke of undetermined source, a new clinical entity particularly refers to patients with embolic stroke for whom the etiology of embolism remains unidentified despite through investigations ruling out established cardiac and vascular sources. In this article, we review current classification and discuss important clinical considerations in these patients; highlighting cardiac arrhythmias and structural abnormalities, patent foramen ovale, paradoxical sources, and potentially under-recognized, vascular, inflammatory, autoimmune, and hematologic sources in relation to clinical practice.
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Affiliation(s)
- Amre Nouh
- Hartford Hospital, University of Connecticut , Hartford, CT , USA
| | - Mohammed Hussain
- Hartford Hospital, University of Connecticut , Hartford, CT , USA
| | - Tapan Mehta
- Hartford Hospital, University of Connecticut , Hartford, CT , USA
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