1
|
Ntaios G, Baumgartner H, Doehner W, Donal E, Edvardsen T, Healey JS, Iung B, Kamel H, Kasner SE, Korompoki E, Navi BB, Pristipino C, Saba L, Schnabel RB, Svennberg E, Lip GYH. Embolic strokes of undetermined source: a clinical consensus statement of the ESC Council on Stroke, the European Association of Cardiovascular Imaging and the European Heart Rhythm Association of the ESC. Eur Heart J 2024; 45:1701-1715. [PMID: 38685132 PMCID: PMC11107123 DOI: 10.1093/eurheartj/ehae150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
One in six ischaemic stroke patients has an embolic stroke of undetermined source (ESUS), defined as a stroke with unclear aetiology despite recommended diagnostic evaluation. The overall cardiovascular risk of ESUS is high and it is important to optimize strategies to prevent recurrent stroke and other cardiovascular events. The aim of clinicians when confronted with a patient not only with ESUS but also with any other medical condition of unclear aetiology is to identify the actual cause amongst a list of potential differential diagnoses, in order to optimize secondary prevention. However, specifically in ESUS, this may be challenging as multiple potential thromboembolic sources frequently coexist. Also, it can be delusively reassuring because despite the implementation of specific treatments for the individual pathology presumed to be the actual thromboembolic source, patients can still be vulnerable to stroke and other cardiovascular events caused by other pathologies already identified during the index diagnostic evaluation but whose thromboembolic potential was underestimated. Therefore, rather than trying to presume which particular mechanism is the actual embolic source in an ESUS patient, it is important to assess the overall thromboembolic risk of the patient through synthesis of the individual risks linked to all pathologies present, regardless if presumed causally associated or not. In this paper, a multi-disciplinary panel of clinicians/researchers from various backgrounds of expertise and specialties (cardiology, internal medicine, neurology, radiology and vascular surgery) proposes a comprehensive multi-dimensional assessment of the overall thromboembolic risk in ESUS patients through the composition of individual risks associated with all prevalent pathologies.
Collapse
Affiliation(s)
- George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Larissa 41132, Greece
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Wolfram Doehner
- Department of Cardiology (Campus Virchow), Center of Stroke Research Berlin, German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin Institute of Health-Center for Regenerative Therapies, Deutsches Herzzentrum der Charité, Charité, Berlin, Germany
| | - Erwan Donal
- Service de Cardiologie et CIC-IT 1414, CHU Rennes, Rennes, France
| | - Thor Edvardsen
- Department of Cardiology, Faculty of Medicine, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway
| | - Jeff S Healey
- Cardiology Division, McMaster University, Hamilton, Canada
| | - Bernard Iung
- Bichat Hospital, APHP and Université Paris-Cité, INSERM LVTS U1148, Paris, France
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Scott E Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eleni Korompoki
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian Pristipino
- Interventional and Intensive Cardiology Unit, San Filippo Neri Hospital, ASL Roma 1, Rome, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari—Polo di Monserrato, Cagliari, Italy
| | - Renate B Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany
| | - Emma Svennberg
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Fang J, Wu J, Hong G, Zheng L, Yu L, Liu X, Lin P, Yu Z, Chen D, Lin Q, Jing C, Zhang Q, Wang C, Zhao J, Yuan X, Wu C, Zhang Z, Guo M, Zhang J, Zheng J, Lei A, Zhang T, Lan Q, Kong L, Wang X, Wang Z, Ma Q. Cancer screening in hospitalized ischemic stroke patients: a multicenter study focused on multiparametric analysis to improve management of occult cancers. EPMA J 2024; 15:53-66. [PMID: 38463627 PMCID: PMC10923752 DOI: 10.1007/s13167-024-00354-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/02/2024] [Indexed: 03/12/2024]
Abstract
Background/aims The reciprocal promotion of cancer and stroke occurs due to changes in shared risk factors, such as metabolic pathways and molecular targets, creating a "vicious cycle." Cancer plays a direct or indirect role in the pathogenesis of ischemic stroke (IS), along with the reactive medical approach used in the treatment and clinical management of IS patients, resulting in clinical challenges associated with occult cancer in these patients. The lack of reliable and simple tools hinders the effectiveness of the predictive, preventive, and personalized medicine (PPPM/3PM) approach. Therefore, we conducted a multicenter study that focused on multiparametric analysis to facilitate early diagnosis of occult cancer and personalized treatment for stroke associated with cancer. Methods Admission routine clinical examination indicators of IS patients were retrospectively collated from the electronic medical records. The training dataset comprised 136 IS patients with concurrent cancer, matched at a 1:1 ratio with a control group. The risk of occult cancer in IS patients was assessed through logistic regression and five alternative machine-learning models. Subsequently, select the model with the highest predictive efficacy to create a nomogram, which is a quantitative tool for predicting diagnosis in clinical practice. Internal validation employed a ten-fold cross-validation, while external validation involved 239 IS patients from six centers. Validation encompassed receiver operating characteristic (ROC) curves, calibration curves, decision curve analysis (DCA), and comparison with models from prior research. Results The ultimate prediction model was based on logistic regression and incorporated the following variables: regions of ischemic lesions, multiple vascular territories, hypertension, D-dimer, fibrinogen (FIB), and hemoglobin (Hb). The area under the ROC curve (AUC) for the nomogram was 0.871 in the training dataset and 0.834 in the external test dataset. Both calibration curves and DCA underscored the nomogram's strong performance. Conclusions The nomogram enables early occult cancer diagnosis in hospitalized IS patients and helps to accurately identify the cause of IS, while the promotion of IS stratification makes personalized treatment feasible. The online nomogram based on routine clinical examination indicators of IS patients offered a cost-effective platform for secondary care in the framework of PPPM. Supplementary Information The online version contains supplementary material available at 10.1007/s13167-024-00354-8.
Collapse
Affiliation(s)
- Jie Fang
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
- School of Medicine, Xiamen University, Xiamen, China
| | - Jielong Wu
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- School of Medicine, Xiamen University, Xiamen, China
- National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen, China
| | - Ganji Hong
- Cerebrovascular Interventional Department, Zhangzhou Hospital of Fujian Province, Zhangzhou, China
| | - Liangcheng Zheng
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Lu Yu
- Department of Neurology, Changxing People’s Hospital, Huzhou, China
| | - Xiuping Liu
- Department of Neurology, The Jilin Center Hospital, Jilin, China
| | - Pan Lin
- Department of Neurology, The Second Hospital of Longyan City, Longyan, China
| | - Zhenzhen Yu
- Department of Neurology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Dan Chen
- Department of Neurology, Xiamen Haicang Hospital, Xiamen, China
| | - Qing Lin
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Chuya Jing
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Qiuhong Zhang
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Chen Wang
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Jiedong Zhao
- School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Xiaodong Yuan
- Department of Gynecology of Xiamen Maternal and Child Health Care Hospital, Xiamen, China
| | - Chunfang Wu
- Department of Neurology, Huaihe Hospital, Henan University, Huaihe, China
| | - Zhaojie Zhang
- Department of Neurology, Kaifeng Hospital of Traditional Chinese Medicine, Kaifeng, China
| | - Mingwei Guo
- Department of Neurology, First Affiliated Hospital of Gannan Medical University, Gannan, China
| | - Junde Zhang
- Department of Neurology, First Affiliated Hospital of Gannan Medical University, Gannan, China
| | - Jingjing Zheng
- Department of Neurology, Ningde Municipal Hospital of Ningde Normal University, Ningde, China
| | - Aidi Lei
- Department of Neurology, The Fifth Hospital of Xiamen, Xiamen, China
| | - Tengkun Zhang
- Department of Neurology, The Fifth Hospital of Xiamen, Xiamen, China
| | - Quan Lan
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | | | - Xinrui Wang
- NHC Key Laboratory of Technical Evaluation of Fertility Regulation for Non-Human Primate (Fujian Maternity and Child Health Hospital), No. 19 Jinjishan Road, Jin’an District, Fuzhou, 350013 China
- Medical Research Center, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Maternityand Child Health Hospital, Fujian Medical University, Fuzhou, China
| | - Zhanxiang Wang
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
- School of Medicine, Xiamen University, Xiamen, China
- National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen, China
- Department of Neurosurgery and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
| | - Qilin Ma
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
- School of Medicine, Xiamen University, Xiamen, China
- National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen, China
| |
Collapse
|
6
|
Lun R, Siegal D, Ramsay T, Stotts G, Dowlatshahi D. Synthetic data in cancer and cerebrovascular disease research: A novel approach to big data. PLoS One 2024; 19:e0295921. [PMID: 38324588 PMCID: PMC10849264 DOI: 10.1371/journal.pone.0295921] [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: 02/23/2023] [Accepted: 12/01/2023] [Indexed: 02/09/2024] Open
Abstract
OBJECTIVES Synthetic datasets are artificially manufactured based on real health systems data but do not contain real patient information. We sought to validate the use of synthetic data in stroke and cancer research by conducting a comparison study of cancer patients with ischemic stroke to non-cancer patients with ischemic stroke. DESIGN retrospective cohort study. SETTING We used synthetic data generated by MDClone and compared it to its original source data (i.e. real patient data from the Ottawa Hospital Data Warehouse). OUTCOME MEASURES We compared key differences in demographics, treatment characteristics, length of stay, and costs between cancer patients with ischemic stroke and non-cancer patients with ischemic stroke. We used a binary, multivariable logistic regression model to identify risk factors for recurrent stroke in the cancer population. RESULTS Using synthetic data, we found cancer patients with ischemic stroke had a lower prevalence of hypertension (52.0% in the cancer cohort vs 57.7% in the non-cancer cohort, p<0.0001), and a higher prevalence of chronic obstructive pulmonary disease (COPD: 8.5% vs 4.7%, p<0.0001), prior ischemic stroke (1.7% vs 0.1%, p<0.001), and prior venous thromboembolism (VTE: 8.2% vs 1.5%, p<0.0001). They also had a longer length of stay (8 days [IQR 3-16] vs 6 days [IQR 3-13], p = 0.011), and higher costs associated with their stroke encounters: $11,498 (IQR $4,440 -$20,668) in the cancer cohort vs $8,084 (IQR $3,947 -$16,706) in the non-cancer cohort (p = 0.0061). A multivariable logistic regression model identified 5 predictors for recurrent ischemic stroke in the cancer cohort using synthetic data; 3 of the same predictors identified using real patient data with similar effect measures. Summary statistics between synthetic and original datasets did not significantly differ, other than slight differences in the distributions of frequencies for numeric data. CONCLUSION We demonstrated the utility of synthetic data in stroke and cancer research and provided key differences between cancer and non-cancer patients with ischemic stroke. Synthetic data is a powerful tool that can allow researchers to easily explore hypothesis generation, enable data sharing without privacy breaches, and ensure broad access to big data in a rapid, safe, and reliable fashion.
Collapse
Affiliation(s)
- Ronda Lun
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Deborah Siegal
- School of Epidemiology, University of Ottawa, Ottawa, Canada
- Division of Hematology, Department of Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Tim Ramsay
- School of Epidemiology, University of Ottawa, Ottawa, Canada
| | - Grant Stotts
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Dar Dowlatshahi
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Canada
| |
Collapse
|
7
|
Fukui S, Wada H, Ikeda K, Kobayashi M, Shimada Y, Nakazawa Y, Mizutani H, Ichikawa Y, Nishiura Y, Moritani I, Yamanaka Y, Inoue H, Shimaoka M, Shimpo H, Shiraki K. Detection of a Prethrombotic State in Patients with Hepatocellular Carcinoma, Using a Clot Waveform Analysis. Clin Appl Thromb Hemost 2024; 30:10760296241246002. [PMID: 38591954 PMCID: PMC11005492 DOI: 10.1177/10760296241246002] [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: 01/04/2024] [Revised: 03/14/2024] [Accepted: 03/21/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Although hepatocellular carcinoma (HCC) is frequently associated with thrombosis, it is also associated with liver cirrhosis (LC) which causes hemostatic abnormalities. Therefore, hemostatic abnormalities in patients with HCC were examined using a clot waveform analysis (CWA). Methods: Hemostatic abnormalities in 88 samples from HCC patients, 48 samples from LC patients and 153 samples from patients with chronic liver diseases (CH) were examined using a CWA-activated partial thromboplastin time (APTT) and small amount of tissue factor induced FIX activation (sTF/FIXa) assay. Results: There were no significant differences in the peak time on CWA-APTT among HCC, LC, and CH, and the peak heights of CWA-APTT were significantly higher in HCC and CH than in HVs and LC. The peak heights of the CWA-sTF/FIXa were significantly higher in HCC than in LC. The peak times of the CWA-APTT were significantly longer in stages B, C, and D than in stage A or cases of response. In the receiver operating characteristic (ROC) curve, the fibrin formation height (FFH) of the CWA-APTT and CWA-sTF/FIXa showed the highest diagnostic ability for HCC and LC, respectively. Thrombosis was observed in 13 HCC patients, and arterial thrombosis and portal vein thrombosis were frequently associated with HCC without LC and HCC with LC, respectively. In ROC, the peak time×peak height of the first derivative on the CWA-sTF/FIXa showed the highest diagnostic ability for thrombosis. Conclusion: The CWA-APTT and CWA-sTF/FIXa can increase the evaluability of HCC including the association with LC and thrombotic complications.
Collapse
Affiliation(s)
- Shunsuke Fukui
- Research Center, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Hideo Wada
- Research Center, Mie Prefectural General Medical Center, Yokkaichi, Japan
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Kohei Ikeda
- Research Center, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Mayu Kobayashi
- Department of Gastroenterology, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Yasuaki Shimada
- Department of Gastroenterology, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Yuuichi Nakazawa
- Department of Gastroenterology, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Hiroki Mizutani
- Department of Gastroenterology, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Yuhuko Ichikawa
- Department of Central Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Yuuki Nishiura
- Department of Gastroenterology, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Isao Moritani
- Department of Gastroenterology, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Yutaka Yamanaka
- Department of Gastroenterology, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Hidekazu Inoue
- Department of Gastroenterology, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hideto Shimpo
- Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Katsuya Shiraki
- Research Center, Mie Prefectural General Medical Center, Yokkaichi, Japan
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan
- Department of Gastroenterology, Mie Prefectural General Medical Center, Yokkaichi, Japan
| |
Collapse
|
8
|
Chae WH, Vössing A, Li Y, Deuschl C, Milles LS, Kühne Escolà J, Hüsing A, Darkwah Oppong M, Dammann P, Glas M, Forsting M, Kleinschnitz C, Köhrmann M, Frank B. Treatment of acute ischemic stroke in patients with active malignancy: insight from a comprehensive stroke center. Ther Adv Neurol Disord 2023; 16:17562864231207508. [PMID: 37920861 PMCID: PMC10619344 DOI: 10.1177/17562864231207508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/25/2023] [Indexed: 11/04/2023] Open
Abstract
Background Despite the high incidence of acute ischemic stroke (AIS) in cancer patients, there is still no consensus about the safety of recanalization therapies in this cohort. Objectives In this observational study, our aim was to investigate the bleeding risk after acute recanalization therapy in AIS patients with active malignancy. Methods and Study Design We retrospectively analyzed observational data of 1016 AIS patients who received intravenous thrombolysis with rtPA (IVT) and/or endovascular therapy (EVT) between January 2017 and December 2020 with a focus on patients with active malignancy. The primary safety endpoint was the occurrence of stroke treatment-related major bleeding events, that is, symptomatic intracranial hemorrhage (SICH) and/or relevant systemic bleeding. The primary efficacy endpoint was neurological improvement during hospital stay (NI). Results None of the 79 AIS patients with active malignancy suffered from stroke treatment-related systemic bleeding. The increased rate (7.6% versus 4.7%) of SICH after therapy compared to the control group was explained by confounding factors. A total of nine patients with cerebral tumor manifestation received acute stroke therapy, two of them suffered from stroke treatment-related intracranial hemorrhage remote from the tumor, both asymptomatic. The group of patients with active malignancy and the control group showed comparable rates of NI. Conclusion Recanalization therapy in AIS patients with active malignancy was not associated with a higher risk for stroke treatment-related systemic or intracranial bleeding. IVT and/or EVT can be regarded as a safe therapy option for AIS patients with active malignancy.
Collapse
Affiliation(s)
- Woon Hyung Chae
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Annika Vössing
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Yan Li
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Lennart Steffen Milles
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Jordi Kühne Escolà
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Anika Hüsing
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Martin Glas
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Martin Köhrmann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Benedikt Frank
- Department of Neurology, University Hospital Essen, Hufelandstraße 55, Essen 45147, Germany
| |
Collapse
|
9
|
Tang KJY, Saffari SE, Narasimhalu K, Queck KK, De Silva DA. Non-Hypertensives and Those with Normal Cholesterol Are More Likely to Have Concomitant Cancer amongst Patients with Ischemic Stroke: A Retrospective Cross-Sectional Registry-Based Study. Cerebrovasc Dis Extra 2023; 13:75-82. [PMID: 37778336 PMCID: PMC10616664 DOI: 10.1159/000534267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/15/2023] [Indexed: 10/03/2023] Open
Abstract
INTRODUCTION Patients with cancer are known to have an increased risk of ischemic stroke (IS) around the time of their diagnosis. However, there is a paucity of data in Asian populations, and as such, we aimed to determine cancer incidence rates and patterns in Asian IS patients as well as investigate the differences in vascular risk profile of IS patients with and without concomitant cancer. METHODS We conducted a retrospective cross-sectional study using data from the Singapore Stroke and Cancer registries. We defined cases as patients with IS and a cancer diagnosis 2 years before or after the index IS. Cancer incidence was determined using the same direct age-standardization method performed for the Singapore general population in the 2015 Singapore cancer report. Multivariable logistic regression was used to analyze differences in vascular risk factors. RESULTS Among 21,068 IS patients (mean age, 67.9 ± 13.3 years), 6.3% (1,330) were found to have concomitant cancer; 4.4% (935) had prior cancer while 1.8% (395) had cancer diagnoses within 2 years following IS. The cancer incidence among IS patients was 3,393 (95% confidence interval [CI], 1,937-4,849) per 100,000 person-years compared to 219-231 per 100,000 person-years in the general population. Older age (odds ratio [OR], 1.02 [95% CI, 1.01-1.02] per year), males (OR, 1.25 [95% CI, 1.11-1.41), Chinese ethnicity (OR, 1.61 [95% CI, 1.37-1.89]) and a lower prevalence of hypertension (OR, 0.84 [95% CI, 0.73-0.97)]), and hyperlipidemia (OR, 0.53 [95% CI, 0.45-0.62]) were independently associated with cancer-related IS. CONCLUSIONS The age-standardized cancer incidence was 15 times higher in IS patients than the general population. IS patients with concomitant cancer were older and had a lower prevalence of vascular risk factors.
Collapse
Affiliation(s)
| | - Seyed Ehsan Saffari
- Duke-NUS Medical School, Centre of Quantitative Medicine, Singapore, Singapore
| | - Kaavya Narasimhalu
- Duke-NUS Medical School, Singapore, Singapore
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus), Singapore, Singapore
| | - Kian Kheng Queck
- KK Queck Neurology Centre, Mount Alvernia Hospital, Singapore, Singapore
| | - Deidre Anne De Silva
- Duke-NUS Medical School, Singapore, Singapore
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus), Singapore, Singapore
| |
Collapse
|
10
|
Prabakar D, Sabesan V, Emenogu OP, Mai C. Recurrent Multifocal Embolic Strokes in a 50-Year-Old Male: Unmasking Occult Squamous Cell Carcinoma. Cureus 2023; 15:e45091. [PMID: 37842450 PMCID: PMC10568952 DOI: 10.7759/cureus.45091] [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] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Abstract
Recurrent cryptogenic embolic strokes pose a diagnostic challenge, often necessitating an extensive evaluation to determine the underlying cause. Cancer-related stroke is a frequently overlooked etiology, accounting for a substantial proportion of cryptogenic strokes. This case study underscores the importance of considering occult malignancies in patients with recurrent strokes of unknown origin and emphasizes the need for a comprehensive diagnostic workup to detect hidden malignancies. A 50-year-old male with a complex medical history presented with expressive aphasia and blurred vision resembling previous stroke episodes. Neurological examinations revealed right hemianopsia, paraphasia, and abnormal coordination. Neuroimaging studies showed multiple chronic infarctions, a large hemorrhagic infarction in the left posterior cerebral artery territory, and a small acute-to-subacute left parietal infarction. Due to the time of presentation and the presence of hemorrhagic transformation, the patient did not meet the criteria for intravenous tissue plasminogen activator administration. Given the recurrent nature of the strokes, an extensive evaluation was initiated to determine the underlying cause. Vascular imaging, including magnetic resonance angiography (MRA) of the head and neck and a CT angiogram, showed no significant stenosis. Vasculitis workup and cardiac evaluation yielded negative results. The blood workup was notable for elevated D-dimer levels. The involvement of multiple vascular territories and recurrent stroke despite adequate treatment and the absence of traditional risk factors for stroke raised a high clinical suspicion of occult malignancy. Further investigations led to the diagnosis of locally advanced squamous cell carcinoma (P16+), metastatic to the right neck lymph nodes (cTxN3M0). Although the primary source of cancer could not be identified, the P16+ status suggests the right tonsil or base of the tongue as the probable origin. Anticoagulation therapy was initiated, and the patient was scheduled for chemoradiation therapy. Although routine cancer investigation is not justified in ischemic strokes, the possibility of an occult malignancy should be considered in the presence of multifocal infarctions across different vascular territories with elevated D-dimer levels, particularly when traditional risk factors have been ruled out. A detailed physical exam can help localize the malignancy and early identification of occult malignancies can guide appropriate management strategies and help prevent future strokes. Further clinical trials are needed to establish optimal therapeutic approaches for preventing stroke recurrence in cancer-related strokes.
Collapse
Affiliation(s)
- Deipthan Prabakar
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Vaishnavi Sabesan
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Oluwasegun P Emenogu
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Cuc Mai
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| |
Collapse
|
11
|
Costamagna G, Hottinger A, Milionis H, Lambrou D, Salerno A, Strambo D, Livio F, Navi BB, Michel P. Clinical and Demographic Characteristics, Mechanisms, and Outcomes in Patients With Acute Ischemic Stroke and Newly Diagnosed or Known Active Cancer. Neurology 2023; 100:e2477-e2489. [PMID: 37094994 PMCID: PMC10264053 DOI: 10.1212/wnl.0000000000207341] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/09/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with a new diagnosis of cancer carry an increased risk of acute ischemic stroke (AIS), and this risk varies depending on age, cancer type, stage, and time from diagnosis. Whether patients with AIS with a new diagnosis of neoplasm represent a distinct subset from those with a previously known active malignancy remains unclear. We aimed to estimate the rate of stroke in patients with newly diagnosed cancer (NC) and previously known active cancer (KC) and to compare the demographic and clinical features, stroke mechanisms, and long-term outcomes between groups. METHODS Using 2003-2021 data from the Acute STroke Registry and Analysis of Lausanne registry, we compared patients with KC with patients with NC (cancer identified during AIS hospitalization or within the following 12 months). Patients with inactive and no history of cancer were excluded. Outcomes were the modified Rankin scale (mRS) score at 3 months and mortality and recurrent stroke at 12 months. We used multivariable regression analyses to compare outcomes between groups while adjusting for important prognostic variables. RESULTS Among 6,686 patients with AIS, 362 (5.4%) had active cancer (AC), including 102 (1.5%) with NC. Gastrointestinal and genitourinary cancers were the most frequent cancer types. Among all patients with AC, 152 (42.5%) AISs were classified as cancer related, with nearly half of these cases attributed to hypercoagulability. In multivariable analysis, patients with NC had less prestroke disability (adjusted odds ratio [aOR] 0.62, 95% CI 0.44-0.86) and fewer prior stroke/transient ischemic attack events (aOR 0.43, 95% CI 0.21-0.88) than patients with KC. Three-month mRS scores were similar between cancer groups (aOR 1.27, 95% CI 0.65-2.49) and were predominantly driven by the presence of newly diagnosed brain metastases (aOR 7.22, 95% CI 1.49-43.17) and metastatic cancer (aOR 2.19, 95% CI 1.22-3.97). At 12 months, mortality risk was higher in patients with NC vs patients with KC (hazard ratio [HR] 2.11, 95% CI 1.38-3.21), while recurrent stroke risk was similar between groups (adjusted HR 1.27, 95% CI 0.67-2.43). DISCUSSION In a comprehensive institutional registry spanning nearly 2 decades, 5.4% of patients with AIS had AC, a quarter of which were diagnosed during or within 12 months after the index stroke hospitalization. Patients with NC had less disability and prior cerebrovascular disease, but a higher 1-year risk of subsequent death than patients with KC.
Collapse
Affiliation(s)
- Gianluca Costamagna
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Andreas Hottinger
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Haralampos Milionis
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dimitris Lambrou
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexander Salerno
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Davide Strambo
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Françoise Livio
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Babak Benjamin Navi
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Patrik Michel
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
12
|
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.
Collapse
Affiliation(s)
- M Zuber
- Groupe hospitalier Paris Saint-Joseph, université Paris Cité, Paris, France.
| |
Collapse
|
13
|
Johansen MC. The Future of Ischemic Stroke Diagnosis and a Review of Underrecognized Ischemic Stroke Etiologies. Neurotherapeutics 2023; 20:613-623. [PMID: 37157043 PMCID: PMC10275839 DOI: 10.1007/s13311-023-01383-3] [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] [Accepted: 04/19/2023] [Indexed: 05/10/2023] Open
Abstract
Accurate ischemic stroke etiologic determination and diagnosis form the foundation of excellent cerebrovascular care as from it stems initiation of the appropriate secondary prevention strategy as well as appropriate patient education regarding specific risk factors for that subtype. Recurrent stroke rates are highest among those patients who receive an incorrect initial stroke diagnosis. Patient distrust and patient reported depression are also higher. The cause of the ischemic stroke also informs predicted patient outcomes and the anticipated recovery trajectory. Finally, determining the accurate cause of the ischemic stroke provides the patient the opportunity to enroll in appropriate research studies studying mechanism, or targeting treatment approaches for that particular disease process. Advances in ischemic stroke research, imaging techniques, biomarkers, and the ability to rapidly perform genetic sequencing over the past decade have shown that classifying patients into large etiologic buckets may not always be appropriate and may represent one reason why some patients are labeled as cryptogenic, or for whom an underlying etiology is never found. Aside from the more traditional stroke mechanisms, there is new research emerging regarding clinical findings that are not normative, but the contributions to ischemic stroke are unclear. In this article, we first review the essential steps to accurate ischemic stroke etiologic classification and then transition to a discussion of embolic stroke of undetermined source (ESUS) and other new entities that have been postulated as causal in ischemic stroke (i.e., genetics and subclinical atherosclerosis). We also discuss the limitations that are inherent in the current ischemic stroke diagnostic algorithms and finally review the most recent studies regarding more uncommon diagnoses and the future of stroke diagnostics and classification.
Collapse
|
14
|
Cen G, Song Y, Chen S, Liu L, Wang J, Zhang J, Li J, Li G, Li H, Liang H, Liang Z. The investigation on the hypercoagulability of hepatocellular carcinoma-related cerebral infarction with thromboelastography. Brain Behav 2023; 13:e2961. [PMID: 36929158 PMCID: PMC10097062 DOI: 10.1002/brb3.2961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 01/21/2023] [Accepted: 02/28/2023] [Indexed: 03/18/2023] Open
Abstract
AIM To investigate the hypercoagulability of hepatocellular carcinoma (HCC)-related cerebral infarction (HCRCI) with thromboelastography (TEG). METHODS A multicenter prospective study was conducted in HCRCI patients, HCC patients without cerebral infarction, and acute cerebral infarction (ACI) patients without HCC between January 2016 and December 2019. TEG parameters and laboratory and clinical data were collected and compared among the three groups. To confirm the independent risk factors of HCRCI, multivariate analyses were conducted. Receiver operating characteristic (ROC) curves were utilized to evaluate the area under the curve (AUC) plotted by each independent risk factor. RESULTS There were 38 patients recruited in the HCRCI group, and 152 patients were recruited to the HCC group and the ACI group. The levels of plasma neutrophil count, D-dimer, α-fetoprotein (AFP), carcinoembryonic antigen, and maximum amplitude (MA)-a parameter of TEG-were significantly higher in the HCRCI group than HCC and ACI groups. Multivariate logistic regression analysis showed that increased neutrophile count, D-dimer, AFP, and MA were independently associated with HCRCI. ROC curve analysis showed first that AUC of MA for HCRCI was .875, which was larger than the other risk factors, and second that the optimal cutoff value for MA was 61.35, with a sensitivity of 89.50% and specificity of 66.40%. CONCLUSION It was suggested that TEG disclosed that the pathogenesis of HCRIC is exactly related to the hypercoagulability. And with a cutoff value of MA equaling to 61.35, TEG facilitates clinicians to identify HCC patients at high risk of HCRIC.
Collapse
Affiliation(s)
- Gengyu Cen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yiting Song
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shijian Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Liuyu Liu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jun Wang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jian Zhang
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jing Li
- Department of Neurology, The Affiliated Tumor Hospital of Guangxi Medical University, Nanning, China
| | - Guohui Li
- Department of Neurology, Wuzhou Red Cross Hospital, Wuzhou, China
| | - Haihua Li
- Department of Neurology, Fusui County People's Hospital, Chongzuo, China
| | - Hongbin Liang
- Department of Neurology, Cenxi People's Hospital, Cenxi, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| |
Collapse
|
15
|
Akyea RK, Iyen B, Georgiopoulos G, Kai J, Qureshi N, Ntaios G. Cardiovascular outcomes and mortality after incident ischaemic stroke in patients with a recent cancer history. Eur J Intern Med 2023; 109:50-57. [PMID: 36549951 DOI: 10.1016/j.ejim.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 12/07/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Up to 10% of patients with ischaemic stroke have comorbid cancer and stroke in these patients is thought to have a poor short-term prognosis. There is little known about the long-term cardiovascular morbidity and mortality outcomes after incident ischaemic stroke in patients with recent cancer history. OBJECTIVE To assess the risk of subsequent cardiovascular morbidity and mortality outcomes in patients with an incident ischaemic stroke and recent cancer history. METHODS Patients aged ≥18 years with an incident ischaemic stroke between 1998 and 2017, with any diagnosis of cancer within 12 months before the stroke event, and no prior history of serious vascular event were identified from UK Clinical Practice Research Datalink (CPRD GOLD) linked to Hospital Episode Statistics (HES) data. To minimize selection bias, these patients were propensity-score matched with patients with incident ischaemic stroke and no history of cancer. Propensity-score matching was done using covariates such as demographic data, vascular risk factors, comorbid conditions, and prescribed medication. Multivariable models (Competing risks and Cox regression) were used to determine the risk of subsequent major adverse cardiovascular event (MACE) outcomes and all-cause mortality. RESULTS Our cohort included 22,460 patients with a median age of 75 (IQR 64-83) years and a follow-up of 12.3 (IQR 7.2-16.7) years. Recent cancer was identified in 1,149 patients (5.1%) at the time of incident ischaemic stroke. The patients with recent cancer history had a lower risk of composite MACE (sub-distribution hazard ratio (SHR) 0.83 [95% CI: 0.75-0.92]) and recurrent stroke (SHR 0.85 95% CI:0.75-0.96]) and a higher risk of all-cause mortality (hazard ratio 1.67 [95% CI:1.47-1.91]). The risk of coronary heart disease, peripheral vascular disease, heart failure, and CVD-related death outcomes did not differ significantly between the groups. CONCLUSIONS After incident ischaemic stroke, patients with recent cancer history have a lower risk of composite MACE and recurrent stroke outcomes but a higher risk of all-cause mortality when compared with patients without a prior history of cancer.
Collapse
Affiliation(s)
- Ralph K Akyea
- Primary Care Stratified Medicine, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
| | - Barbara Iyen
- Primary Care Stratified Medicine, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Georgios Georgiopoulos
- School of Biomedical Engineering and Imaging Sciences, St Thomas Hospital, King's College London, London, United Kingdom
| | - Joe Kai
- Primary Care Stratified Medicine, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Nadeem Qureshi
- Primary Care Stratified Medicine, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| |
Collapse
|
16
|
Seystahl K, Gramatzki D, Wanner M, Weber SJ, Hug A, Luft AR, Rohrmann S, Wegener S, Weller M. A risk model for prediction of diagnosis of cancer after ischemic stroke. Sci Rep 2023; 13:111. [PMID: 36596831 PMCID: PMC9810715 DOI: 10.1038/s41598-022-26790-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 12/20/2022] [Indexed: 01/05/2023] Open
Abstract
It remains controversial which characteristics may predict occult cancer in stroke patients. Characteristics of patients with ischemic stroke registered in the Zurich Swiss Stroke Registry (2014 to 2016) were tested for associations with cancer diagnosis after stroke with consideration of death as competing risk for cancer diagnosis. Among 1157 patients, 34 (3%) and 55 patients (5%) were diagnosed with cancer within 1 and 3 years after stroke. Levels of white blood cells (WBC) > 9,600/µl (subdistribution hazard ratio (SHR) 3.68, p = 0.014), platelets > 400,000/µl (SHR 7.71, p = 0.001), and d-dimers ≥ 3 mg/l (SHR 3.67, p = 0.007) were independently associated with cancer diagnosis within 1 year after stroke. Occurrence of ischemic lesions in ≥ 2 vascular territories not attributed to cardioembolic etiology was associated with cancer diagnosed within 1 year after stroke in univariable analysis (SHR 3.69, p = 0.001). The area under the curve of a score from these parameters (score sum 0-4) was 0.73. A score of ≥ 2 had a sensitivity of 43% and specificity of 92% for prediction of cancer diagnosis within 1 year after stroke. We suggest further validation of a score of WBC, platelets, d-dimers and multiple ischemic lesions without cardioembolic stroke etiology for prediction of cancer diagnosis after stroke.
Collapse
Affiliation(s)
- Katharina Seystahl
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland
| | - Dorothee Gramatzki
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland
| | - Miriam Wanner
- grid.7400.30000 0004 1937 0650Cancer Registry of the Cantons of Zurich, Zug, Schaffhausen and Schwyz, University Hospital and University of Zurich, Zurich, Switzerland
| | - Sung Ju Weber
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland
| | - Alessia Hug
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland
| | - Andreas R. Luft
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland ,grid.512634.7Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Sabine Rohrmann
- grid.7400.30000 0004 1937 0650Cancer Registry of the Cantons of Zurich, Zug, Schaffhausen and Schwyz, University Hospital and University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland
| | - Michael Weller
- grid.7400.30000 0004 1937 0650Department of Neurology, University Hospital and University of Zurich, CH-8091 Zurich, Switzerland
| |
Collapse
|
17
|
Zamora C, Castillo M, Puac-Polanco P, Torres C. Oncologic Emergencies in the Head and Neck. Radiol Clin North Am 2023; 61:71-90. [DOI: 10.1016/j.rcl.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
18
|
Dubenko O. Cancer-associated stroke. УКРАЇНСЬКИЙ РАДІОЛОГІЧНИЙ ТА ОНКОЛОГІЧНИЙ ЖУРНАЛ 2022. [DOI: 10.46879/ukroj.4.2022.52-61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background. Systemic cancer and stroke are the most common diseases and the frequent death factors in older people worldwide. The relationship between cancer and stroke is complex, since cancer leads to an increased risk of stroke through specific pathophysiological mechanisms. Purpose. Analyzing possible mechanisms of development of cancer-associated stroke, strategies of diagnosis and treatment. Materials and methods. The contributions were selected based on PubMed (https://pubmed.ncbi.nlm.nih.gov/), Clinical Key Elsevier (https://www.clinicalkey.com), Cochrane Library (https://www.cochranelibrary.com/) and GoogleScholar (https://scholar.google.com/) databases published from 2012 to 2022, dealing with cancer-associated stroke. Results and discussion. There are several underlying pathophysiological mechanisms of cancer-associated stroke, which may be directly related to cancer or caused by cancer complications. The most common ones are intravascular cancer coagulopathy, non-bacterial thrombotic endocarditis, a direct impact of the tumor on the vascular system or therapeutic and diagnostic interventions for the treatment of cancer that is chemotherapy, radiation therapy complications, as well as activation of the usual mechanisms of stroke, atherosclerosis in particular. The risk of stroke is also related to cancer aggressiveness. The characteristic features of cancer-associated stroke which is related to cancer coagulopathy are multiple lesions in various arterial areas, as well as laboratory data indicating coagulopathy in the form of increased level of D-dimer, elevated C-reactive protein, low hematocrit. Conclusions. Cancer leads to an increased risk of stroke due to specific pathophysiological mechanisms. These mechanisms are multiple and complex, but the most well-known and widespread is cancer intravascular coagulopathy, which has specific laboratory biomarkers. Numerous studies continue investigating the factors associated with coagulopathy in stroke patients, cancer characteristics, and evaluation of biological markers of stroke-causing intravascular coagulopathy, as well as monitoring the effects of anticoagulation therapy in patients with cancer-associated stroke.
Collapse
|
19
|
Cancer and stroke: What do we know and where do we go? Thromb Res 2022; 219:133-140. [PMID: 36179651 DOI: 10.1016/j.thromres.2022.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 11/23/2022]
Abstract
Cancer is an increasingly recognized cause for ischemic stroke, with recent acknowledgement of cancer-related stroke as an emerging stroke subtype with unique pathophysiologic mechanisms. In addition, cancer-related stroke may differ from stroke in the general population as cancer patients may not receive guideline-recommended stroke care, and the occurrence of stroke may also preclude patients from receiving optimal cancer treatments. Due to the high degree of morbidity and mortality associated with both conditions, understanding the relationship between stroke and cancer is crucial. In this narrative review, we discuss the association between cancer and stroke, the unique pathophysiologic mechanisms underlying this phenomenon, treatment options including acute reperfusion therapies and secondary prevention strategies, compare outcomes between cancer-related stroke and stroke in the general population, and review new and emerging evidence in this field.
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Falanga A, Brenner B, Khorana AA, Francis C. Thrombotic complications in patients with cancer: Advances in pathogenesis, prevention, and treatment—A report from ICTHIC 2021. Res Pract Thromb Haemost 2022; 6:e12744. [PMID: 35794962 PMCID: PMC9248072 DOI: 10.1002/rth2.12744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/28/2022] [Accepted: 05/03/2022] [Indexed: 11/05/2022] Open
Abstract
Venous thromboembolism (VTE) is a common complication in cancer patients, resulting in deep vein thrombosis (DVT) or pulmonary embolism (PE), and is responsible for high morbidity and mortality. This article discusses evidence and future perspectives on pathogenesis and prevention and treatment of thrombotic complications in patients with cancer. In April 2021, international basic researchers and clinicians met for the virtual edition of the 10th International Conference on Thrombosis & Hemostasis Issues in Cancer. Pathogenic mechanisms, markers and scores for risk assessment, diagnosis and therapy issues, current prophylaxis recommendations, and special settings, such as palliative care, pediatrics, and COVID‐19 patients were discussed. Emerging areas of interest in cancer associated VTE are the role of immunotherapy, platelet activation markers, genetic alterations and real‐world systems‐based approaches to prevention and treatment.
Collapse
Affiliation(s)
- Anna Falanga
- Division of Immunohematology and Transfusion Medicine Hospital Papa Giovanni XXIII Bergamo Italy
- Department of Medicine and Surgery University of Milan Bicocca Milan Italy
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation Rambam Health Care Campus Haifa Israel
| | - Alok A. Khorana
- Taussig Cancer Institute Cleveland Clinic Lerner College of Medicine Cleveland Clinic Cleveland Ohio USA
| | - Charles W. Francis
- James P Wilmot Cancer Center and University of Rochester Rochester NY USA
| |
Collapse
|
22
|
Beyeler M, Birner B, Branca M, Meinel T, Vynckier J, Buffle E, Scutelnic A, Heldner MR, Bücke P, Seiffge D, Mordasini P, Dobrocky T, Piechowiak EI, Kaesmacher J, Gralla J, Mattle HP, Arnold M, Fischer U, Pabst T, Berger MD, Jung S. Development of a score for prediction of occult malignancy in stroke patients (occult-5 score). J Stroke Cerebrovasc Dis 2022; 31:106609. [PMID: 35753093 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/08/2022] [Accepted: 06/16/2022] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Malignancy associated acute ischemic stroke (AIS) requires specific diagnostic work-up, treatment and prevention to improve outcome. This study aimed to develop a biomarker-based score for prediction of occult malignancy in AIS patients. METHODS Single-center cross-sectional study including consecutive AIS patients treated between July 2017 and November 2018. Patients with active malignancy at presentation, or diagnosed within 1 year thereafter and patients free of malignancy, were included and malignancy associated biomarkers were assessed. LASSO analyses of logistic regression were performed to determine biomarkers predictive of active malignancy. Predictors were derived from a predictive model for active malignancy. A comparison between known and unknown (=occult) malignancies when the index stroke occurred was used to eliminate variables not associated with occult malignancy. A predictive score (OCCULT-5 score) for occult malignancy was developed based on the remaining variables. RESULTS From 1001 AIS patients, 61 (6%) presented an active malignancy. Thirty-nine (64%) were known and 22 (36%) occult. Five variables were included in the final OCCULT-5 score: age ≥ 77 years, embolic stroke of undetermined source, multi-territorial infarcts, D-dimer levels ≥ 820 µ/gL, and female sex. A score of ≥ 3 predicted an underlying occult malignancy with a sensitivity of 64%, specificity of 73%, positive likelihood ratio of 2.35 and a negative likelihood ratio of 0.50. CONCLUSIONS The OCCULT-5 score might be useful to identify patients with occult malignancy. It may thus contribute to a more effective and timely treatment and thus lead to a positive impact on overall outcome.
Collapse
Affiliation(s)
- Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Switzerland.
| | - Barbara Birner
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | | | - Thomas Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Jan Vynckier
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland; Department of Neurology, Onze Lieve Vrouwziekenhuis Hospital, Aalst, Belgium
| | - Eric Buffle
- ARTORG Center, University of Bern, Bern, Switzerland; Department of Cardiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Pascale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Eike I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Heinrich P Mattle
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland; Neurology Department, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Martin D Berger
- Department of Medical Oncology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| |
Collapse
|
23
|
From cryptogenic to ESUS: Toward precision medicine? Rev Neurol (Paris) 2022; 178:939-952. [PMID: 35597610 DOI: 10.1016/j.neurol.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/11/2022] [Accepted: 01/18/2022] [Indexed: 11/20/2022]
Abstract
Cryptogenic infarctions are infarctions without a defined cause, despite a complete work-up. They differ from infarctions of undetermined causes, which may involve overlapping causes or an incomplete investigation. It is also different from uncommon heritable and non-heritable causes. The term embolic stroke of undetermined source (ESUS) proposed in 2014 is defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources. The major advantage of this definition compared to cryptogenic definition is the proposition of a specific work-up. In a general population, frequent potential sources of embolism in patients with ESUS have been suggested since a long time and include: patent foramen ovale (PFO), covert atrial fibrillation (AF), complex aortic arch atheroma, large vessel atheroma with stenosis<50%, carotid web, atrial cardiomyopathy, thrombophilia associated with cancer. It took almost 30 years to show, in patients under 60 with a cryptogenic stroke and a PFO, that PFO occlusion was superior to medical treatment alone for recurrent stroke. PFO under 60 is therefore no longer a cryptogenic cause of infarction. The concept of cryptogenic stroke and its refinement in ESUS have been fruitful for the identification of PFO associated as a cause. Covert AF can be detected by different techniques but its risk significance for recurrent stroke might be different from the simple electrocardiographic detection of AF. With the development of direct oral anticoagulants (DOAs), randomized studies in patients with ESUS, were run for stroke prevention but no difference was observed between patients treated by DOA compared to aspirin. These studies showed however the heterogeneity of ESUS patients. Further ESUS classification should be considered as a tool to identify homogeneous groups. We propose to further split the ESUS group into different subgroups: ESU-PFO>60-year-old, ESUS-ATH with stenosis<50%, ESUS-AF (covert AF & atrial cardiomyopathy), ESUS-cancer and others. Precision medicine is the ability to make targeted healthcare decisions based on the specific risks of individual patients. One preliminary stage is therefore to identify homogeneous groups suitable in the future for new therapeutic trials and, at the end, for new specific treatments.
Collapse
|
24
|
Simonetto M, Rutrick S, LeMoss NM, Lansdale KN, Tagawa ST, Kamel H, Parikh N, Navi BB. Adherence to Guideline-Recommended Cancer Screening in Stroke Survivors: A Nationwide Analysis. J Stroke Cerebrovasc Dis 2022; 31:106297. [PMID: 35032754 PMCID: PMC8852296 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/23/2021] [Accepted: 12/25/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES Cancer can present as stroke. Several cancer types have established screening guidelines. We investigated adherence to guideline-recommended cancer screening in stroke survivors versus the general population. MATERIALS AND METHODS We performed a cross-sectional analysis using 2012-2018 data from the CDC's Behavioral Risk Factor Surveillance System (BRFSS) survey. BRFSS is a nationally-representative telephone survey of non-institutionalized Americans that collects data about health conditions and behaviors, including cancer screening. We defined guideline-recommended colorectal, lung, and breast cancer screening based on the U.S. Preventive Services Task Force recommendations. We used survey-specific methods to estimate up-to-date screening rates for those with and without prior stroke. We used logistic regression to estimate the odds of up-to-date screening in stroke survivors compared to those without history of stroke after adjustment for potential confounders. RESULTS Among 1,018,440 respondents eligible for colorectal cancer screening, 66% were up-to-date. Among 6,880 respondents eligible for lung cancer screening, 16% were up-to-date. Among 548,434 women eligible for breast cancer screening, 78% were up-to-date. After adjustment for demographics and confounders, stroke survivors were more likely to have up-to-date colorectal cancer screening (OR, 1.10; 95% CI, 1.05-1.16), equally likely to undergo lung cancer screening (OR, 0.99; 95% CI, 0.62-1.59), and less likely to undergo breast cancer screening (OR, 0.87; 95% CI, 0.80-0.94). CONCLUSIONS In a nationwide analysis, stroke survivors had similar suboptimal adherence to guideline-recommended cancer screening as the general population.
Collapse
Affiliation(s)
- Marialaura Simonetto
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States
| | - Stephanie Rutrick
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States
| | - Natalie M. LeMoss
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States
| | - Kelsey N. Lansdale
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States
| | - Scott T. Tagawa
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medicine, New York, United States
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States
| | - Neal Parikh
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States
| | - Babak B. Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Brain and Mind Research Institute, Weill Cornell Medicine, New York, United States,Corresponding Author: 420 East 70th Street, Room 411, New York, NY, USA,
| |
Collapse
|
25
|
Liu Y, Li X, Song F, Yan X, Han Z, Tang F, Li Y. Clinical Features and Prognostic Factors of Acute Ischemic Stroke Related to Malignant Gastrointestinal Tumor. Front Neurol 2021; 12:777483. [PMID: 34899584 PMCID: PMC8655855 DOI: 10.3389/fneur.2021.777483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/07/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives: To analyze the clinical and imaging features of acute ischemic stroke (AIS) related to gastrointestinal malignant tumor, and to explore the prognostic factors. Methods: Clinical data of consecutive patients with gastrointestinal malignant tumor complicated with AIS admitted to the Department of Neurology and Oncology in Lanzhou University Second Hospital from April 2015 to April 2019 were retrospectively analyzed. Patients were divided into good prognosis (mRS 0–2) and poor prognosis (mRS > 2) based on a 90-day mRS score after discharge. The multivariate logistic regression model was used to analyze the prognostic factors. Results: A total of 68 patients were enrolled with an average age of 61.78 ± 6.65 years, including 49 men (72.06%). There were 18 patients in the good prognosis group and 50 patients in the poor prognosis group. The univariate analysis showed that Hcy, D-dimer, thrombin–antithrombin complex (TAT), and three territory sign in magnetic resonance imaging (MRI) were the risk factors for poor prognosis. Multivariate analysis showed that increased D-dimer (OR 4.497, 95% CI 1.014–19.938) and TAT levels (OR 4.294, 95% CI 1.654–11.149) were independent risk factors for the prognosis in such patients. Conclusion: Image of patients with gastrointestinal malignant tumor-related AIS is characterized by three territory sign (multiple lesions in different vascular supply areas). Increased TAT and D-dimer levels are independent prognostic risk factors. TAT is more sensitive to predict prognosis than D-dimer.
Collapse
Affiliation(s)
- Yating Liu
- Department of Oncology, Lanzhou University Second Hospital, Lanzhou, China.,Key Laboratory of the Digestive System Tumors of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
| | - Xin Li
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, China
| | - Feixue Song
- Department of Oncology, Lanzhou University Second Hospital, Lanzhou, China
| | - Xin Yan
- Key Laboratory of the Digestive System Tumors of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
| | - Zhijian Han
- Key Laboratory of the Digestive System Tumors of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
| | - Futian Tang
- Key Laboratory of the Digestive System Tumors of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
| | - Yumin Li
- Key Laboratory of the Digestive System Tumors of Gansu Province, Lanzhou University Second Hospital, Lanzhou, China
| |
Collapse
|
26
|
Score for Predicting Active Cancer in Patients with Ischemic Stroke: A Retrospective Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5585206. [PMID: 34124248 PMCID: PMC8169246 DOI: 10.1155/2021/5585206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/01/2021] [Accepted: 05/18/2021] [Indexed: 12/21/2022]
Abstract
Background We aimed to examine the differences of clinical characteristics between patients with ischemic stroke with active cancer and those without cancer to develop a clinical score for predicting the presence of occult cancer in patients with ischemic stroke. Methods This retrospective study enrolled consecutive adult patients with acute ischemic stroke who were admitted to our department between December 2017 and January 2019. The demographic, clinical, laboratory, and neuroimaging characteristics were compared between patients with ischemic stroke with active cancer and those without cancer. Multivariate analysis was performed to identify independent factors associated with active cancer. Subsequently, a predictive score was developed using the areas under the receiver operating characteristic curves based on these independent factors. Finally, Bayesian decision theory was applied to calculate the posterior probability of active cancer for finding the best scoring system. Results Fifty-three (6.63%) of 799 patients with ischemic stroke had active cancer. The absence of a history of hyperlipidemia (odds ratio (OR) = 0.17, 95% confidence interval (CI): 0.06-0.48, P < 0.01), elevated serum fibrinogen (OR = 1.72, 95% CI: 1.33-2.22, P < 0.01) and D-dimer levels (OR = 1.43, 95% CI: 1.24-1.64, P <0.01), and stroke of undetermined etiology (OR = 22.87, 95% CI: 9.91-52.78, P < 0.01) were independently associated with active cancer. A clinical score based on the absence of hyperlipidemia, serum fibrinogen level of ≥4.00 g/L, and D-dimer level of ≥2.00 μg/mL predicted active cancer with an area under the curve of 0.83 (95% CI: 0.77-0.89, P < 0.01). The probability of active cancer was 59% at a supposed prevalence of 6.63%, if all three independent factors were present in a patient with ischemic stroke. Conclusions We devised a clinical score to predict active cancer in patients with ischemic stroke based on the absence of a history of hyperlipidemia and elevated serum D-dimer and fibrinogen levels. The use of this score may allow for early intervention. Further research is needed to confirm the implementation of this score in clinical settings.
Collapse
|
27
|
Seystahl K, Hug A, Weber SJ, Kapitza S, Gramatzki D, Wanner M, Katan M, Luft AR, Rohrmann S, Wegener S, Weller M. Cancer is associated with inferior outcome in patients with ischemic stroke. J Neurol 2021; 268:4190-4202. [PMID: 33945004 PMCID: PMC8505392 DOI: 10.1007/s00415-021-10528-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/22/2021] [Indexed: 11/12/2022]
Abstract
Background Whether patients with stroke and cancer exhibit specific characteristics has remained controversial. Methods Medical records of patients with ischemic stroke in 2014 or 2015 registered in the Swiss Stroke Registry of Zurich were retrospectively analyzed and integrated with regional cancer registry data. Associations of clinical and outcome parameters with cancer diagnosed up to 5 years prior to stroke were tested. Results Of 753 patients with ischemic stroke, 59 patients with cancer were identified. History of venous thromboembolism (p < 0.001) was associated with cancer while age and cardiovascular risk factors were not. Higher levels of D-dimers (p = 0.001), erythrocyte sedimentation rate (p = 0.003), C-reactive protein (CRP) (p < 0.001), and lower levels of hemoglobin (p = 0.003) were associated with cancer. For platelets, pathologically low (p = 0.034) or high levels (p < 0.001) were linked to cancer. Modified Rankin scale (mRS) scores ≥ 4 on admission and at follow-up were more frequent in cancer patients (p = 0.038 and p = 0.001). Poor post-stroke survival was associated with cancer (HR 2.2, p < 0.001). Multivariable analysis identified venous thromboembolism (OR 5.1), pathologic platelet count (OR = 2.9), low hemoglobin (OR 2.5) and elevated CRP (OR 1.8) as independently associated with cancer. In multivariable Cox regression, risk for death was associated with cancer (HR 1.7), low hemoglobin (HR 2.6), mRS on admission ≥ 4 (HR 1.9), pathologic platelet count (HR 1.6), female sex (HR 1.7), and elevated CRP (HR 1.4). Conclusions Considering cancer as a cofactor for post-stroke outcome may impact clinical decision making. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10528-3.
Collapse
Affiliation(s)
- Katharina Seystahl
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland.
| | - Alessia Hug
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Sung Ju Weber
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Sandra Kapitza
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Dorothee Gramatzki
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Miriam Wanner
- Cancer Registry of the Canton of Zurich, Zug, Schaffhausen and Schwyz, University Hospital and University of Zurich, Zurich, Switzerland
| | - Mira Katan
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Andreas R Luft
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland.,Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Sabine Rohrmann
- Cancer Registry of the Canton of Zurich, Zug, Schaffhausen and Schwyz, University Hospital and University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, CH-8091, Zurich, Switzerland
| |
Collapse
|
28
|
Markus A, Valerie S, Mira K. Promising Biomarker Candidates for Cardioembolic Stroke Etiology. A Brief Narrative Review and Current Opinion. Front Neurol 2021; 12:624930. [PMID: 33716927 PMCID: PMC7947187 DOI: 10.3389/fneur.2021.624930] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/11/2021] [Indexed: 01/09/2023] Open
Abstract
Determining the cause of stroke is considered one of the main objectives in evaluating a stroke patient in clinical practice. However, ischemic stroke is a heterogeneous disorder and numerous underlying disorders are implicated in its pathogenesis. Although progress has been made in identifying individual stroke etiology, in many cases underlying mechanisms still remain elusive. Since secondary prevention strategies are tailored toward individual stroke mechanisms, patients whose stroke etiology is unknown may not receive optimal preventive treatment. Cardioembolic stroke is commonly defined as cerebral vessel occlusion by distant embolization arising from thrombus formation in the heart. It accounts for the main proportion of ischemic strokes, and its share to stroke etiology is likely to rise even further in future decades. However, it can be challenging to distinguish cardioembolism from other possible etiologies. As personalized medicine advances, stroke researchers' focus is increasingly drawn to etiology-associated biomarkers. They can provide deeper insight regarding specific stroke mechanisms and can help to unravel previously undetected pathologies. Furthermore, etiology-associated biomarkers could play an important role in guiding future stroke prevention strategies. To achieve this, broad validation of promising candidate biomarkers as well as their implementation in well-designed randomized clinical trials is necessary. This review focuses on the most-promising candidates for diagnosis of cardioembolic stroke. It discusses existing evidence for possible clinical applications of these biomarkers, addresses current challenges, and outlines future perspectives.
Collapse
Affiliation(s)
- Arnold Markus
- Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
| | - Schütz Valerie
- Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
| | - Katan Mira
- Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
| |
Collapse
|
29
|
Navi BB, Kasner SE, Elkind MSV, Cushman M, Bang OY, DeAngelis LM. Cancer and Embolic Stroke of Undetermined Source. Stroke 2021; 52:1121-1130. [PMID: 33504187 DOI: 10.1161/strokeaha.120.032002] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
One-quarter to one-third of ischemic strokes have no established mechanism after standard diagnostic evaluation and are classified as embolic stroke of undetermined source (ESUS). Failure of randomized trials to demonstrate a benefit of direct oral anticoagulants over aspirin for the treatment of ESUS as a single homogeneous entity has led to renewed interest by stroke experts to divide ESUS into subgroups. Emerging data suggest that active cancer, which is present in 5% to 10% of patients with ESUS, is a distinct and important subgroup of ESUS with unique clinical characteristics, underlying pathophysiologies, and treatment and prognostic considerations. Furthermore, the prevalence of cancer-related ESUS is expected to increase as patients with cancer, even those with distant metastases, survive longer due to improvements in cancer treatments. In this topical review, we examine the epidemiological link between ESUS and cancer, the clinical features and potential mechanistic underpinnings of ESUS with cancer (with a focus on novel biomarkers and their relationship to recurrent stroke and other thromboembolic events), and the potential treatment strategies for cancer-related ESUS. We include a critical appraisal of existing data and ongoing or planned clinical trials of different antithrombotic approaches. As cancer-related ESUS is a dynamic disease with variable course, we recommend close collaboration between neurologists and oncologists to develop individualized management plans.
Collapse
Affiliation(s)
- Babak B Navi
- Clinical and Translational Neuroscience Unit, Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY (B.B.N.).,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY (B.B.N., L.M.D.)
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY (M.S.V.E.)
| | - Mary Cushman
- Division of Hematology and Oncology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington (M.C.)
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.)
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY (B.B.N., L.M.D.)
| |
Collapse
|
30
|
Salazar-Camelo RA, Moreno-Vargas EA, Cardona AF, Bayona-Ortiz HF. Ischemic stroke: A paradoxical manifestation of cancer. Crit Rev Oncol Hematol 2020; 157:103181. [PMID: 33264715 DOI: 10.1016/j.critrevonc.2020.103181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 10/01/2020] [Accepted: 11/11/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Approximately 5-10 % of the patients with cryptogenic stroke have an underlying malignancy. Stroke as a complication of cancer increases the morbidity and mortality among cancer patients, leading to increased disability and healthcare costs. OBJECTIVE To provide elements to guide physicians for when to suspect and evaluate for cancer in stroke patients. DEVELOPMENT We performed a narrative review, portrayed in a question-answer format, to report relevant aspects of cancer stroke patients in the clinical practice and provide a guide based on the state-of-the-art literature. Conventional stroke mechanisms are only found in a fraction of patients with cancer. Although cardiovascular risk factors play an important role in both cancer and stroke pathogenesis, the recognition of more specific cancer-associated risk factors raises clinical suspicion for occult malignancy. We also expose the main type location and histology of tumors that are most commonly associated with stroke as well as potential blood biomarkers and current treatment considerations in the scenario of cancer associated stroke. CONCLUSION Subjects with active cancer are a patient population at increased risk for developing an ischemic stroke. Cryptogenic stroke patients have a higher risk of cancer diagnosis in the following 6-12 months. We recommend a multidisciplinary approach considering the high probability of a hidden malignancy and running a comprehensive evaluation including neurologic imaging, serological biomarkers and tight follow up.
Collapse
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.
| |
Collapse
|
31
|
Tybjerg AJ, Babore AD, Olsen TS, Andersen KK. Types of occult cancer in stroke and the relation to smoking. Acta Neurol Scand 2020; 142:486-492. [PMID: 32562260 DOI: 10.1111/ane.13299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/30/2020] [Accepted: 06/13/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Stroke is associated with a higher risk of occult cancer. We studied the types of occult cancer most often associated with stroke. MATERIALS AND METHODS All patients with incident stroke in Denmark 2003-2015 were identified through the Danish Stroke Registry (n = 85 893) and matched 1:10 on age and sex to the Danish background population without history of stroke (n = 858 740). Linking data to the Danish Cancer Registry, we determined the prevalence of occult cancer in stroke defined as the event of previously unknown cancer during a one-year follow-up in the stroke and the background population. We stratified cancers into the 15 most common cancers and into cancers related to and not related to smoking. RESULTS Prevalence (per 1000 person-years; stroke/background population) of smoking-related occult cancers (lung, colon, bladder rectum, pancreas, kidney, stomach, and head and neck) was 13.3/8.1 (P < .01) and of cancers not related to smoking (prostate, breast, melanoma, non-Hodgkin lymphoma, ovary, endometrial) it was 6.6/6.2 (P > .05). Among men with stroke prostate (5.8), lung (5.7), and colon cancers (2.9) were most frequent; among women, it was lung (4.7), breast(3.5), and colon cancer(2.8). Among men in the background population, prostate(5.4), lung (3.0), and colon cancers (2.1) were most frequent. Among women, it was breast (3.7), lung(2.1), and colon cancers (1.9). CONCLUSION Stroke patients' increased risk of occult cancer was predominantly for smoking-related cancers while there was no higher risk for the most frequent cancers unrelated to smoking, that is, prostate and breast cancers. Lung cancer is the dominant type of occult cancer in stroke.
Collapse
Affiliation(s)
| | | | - Tom Skyhøj Olsen
- Department of Neurology Bispebjerg University Hospital Copenhagen Denmark
| | | |
Collapse
|
32
|
D-dimer and Body CT to Identify Occult Malignancy in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2020; 29:105366. [PMID: 33039769 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/21/2020] [Accepted: 09/24/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND AND AIM Patients with acute ischemic stroke associated with cancer have D-dimer elevations greater than those with acute ischemic stroke or cancer alone. While D-dimer has been proposed as a screening tool to identify such patients, its use in clinical practice to identify malignancy and to inform the use of CT scanning has not been well characterized. METHODS We conducted a retrospective cohort study of patients with acute ischemic stroke to evaluate how D-dimer levels and CT chest, abdomen, and pelvis scanning were used in practice to screen for occult malignancy. Patients were excluded if they had known active cancer and or received tPA. RESULTS Of 480 patients, 254 (53%) had D-dimer measured, 49 (10%) underwent CT screening for cancer, and 11 (2%) had findings concerning for malignancy. There was no difference in D-dimer level between patients who underwent CT evaluation for cancer and those who did not (median 1.01 vs 0.85 p = 0.19). Patients with CT concerning for cancer had higher D-dimer levels than those with a negative CT (median 2.52 vs 0.74 p = 0.01). D-dimer demonstrated moderate discrimination with a c-statistic of 0.77. Selecting a cut point of >1.2 ug/mL (60th percentile of our cohort and 2.4-times the upper limit of normal for our institution's D-dimer assay) provided a sensitivity of 85% and specificity of 65%, a positive likelihood ratio of 2.32, and an odds ratio of 9.6 (95% confidence interval 2.1-44.1, p = 0.004) for having a CT scan concerning for malignancy. CONCLUSIONS Elevated D-dimer levels are suggestive of occult malignancy in acute ischemic stroke patients and should inform selective use of CT to screen for cancer.
Collapse
|
33
|
Wei Y, Yang Q, Qin Q, Chen Y, Quan X, Wei J, Zhou L, Wang D, Li H, Li G, Li S, Liang Z. Profiling of the Risk Factors and Designing of a Model to Identify Ischemic Stroke in Patients with Non-Hodgkin Lymphoma: A Multicenter Retrospective Study. Eur Neurol 2020; 83:41-48. [PMID: 32344398 DOI: 10.1159/000506046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 01/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The occurrence of ischemic stroke in patients with non-Hodgkin lymphoma (NHL) is not well understood. This study aimed to determine independent risk factors to identity ischemic stroke in non-Hodgkin lymphoma-associated ischemic stroke (NHLAIS) patients. METHODS This retrospective study was conducted on NHLAIS patients and age- and gender-matched NHL patients. We collected clinical data of patients in both groups and used multiple logistic regression analysis to identify independent risk factors for NHLAIS. A receiver operating characteristic (ROC) analysis was used to establish an identification model based on potential risk factors of NHLAIS. RESULTS Sixty-three NHLAIS patients and 63 NHL patients were enrolled. Stage III/IV (58/63, 92.1%) and multiple arterial infarcts (44/63, 69.8%) were common among NHLAIS patients. Notably, NHLAIS patients had higher levels of serum fibrinogen (FIB), D-dimer, and ferritin (SF) and prolonged thromboplastin time and prothrombin time (PT) compared with NHL patients (all p < 0.05). Elevated FIB, D-dimer, and SF and prolonged PT were independent risk factors for NHLAIS. The area under the ROC curve of the identification model of NHLAIS patients was largest compared to that of other risk factors (0.838, 95% confidence interval: 0.759-0.899) (p < 0.05). CONCLUSION This study reveals that elevated serum FIB, D-dimer, and SF and prolonged PT are potential independent risk factors of NHLAIS. The identification model established in this study may help monitor NHL patients who are at high risk of developing NHLAIS.
Collapse
Affiliation(s)
- Yunfei Wei
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.,Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Qingqing Yang
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Qixiong Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ya Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xuemei Quan
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jing Wei
- Department of Neurology, The Affiliated Tumor Hospital of Guangxi Medical University, Nanning, China
| | - Liyuan Zhou
- Department of Neurology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Dacheng Wang
- Department of Neurology, The Ninth Affiliated Hospital of Guangxi Medical University, Beihai, China
| | - Haihong Li
- Department of Neurology, Fusui County People's Hospital, Chongzuo, China
| | - Guohui Li
- Department of Neurology, Wuzhou Red Cross Hospital, Wuzhou, China
| | - Shengyu Li
- Department of Neurology, Wuming County People's Hospital, Nanning, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China,
| |
Collapse
|
34
|
Cheng X, Qin Q, Lu L, Chen C, Wei Y, Wang D, Li H, Li G, Liang H, Li S, Cheng D, Liang Z. The independent risks and specific biomarker of breast cancer-related ischemic stroke. Int J Neurosci 2020; 131:135-143. [PMID: 32083954 DOI: 10.1080/00207454.2020.1733562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM This retrospective study was designed to investigate the independent risks and specific biomarker for breast cancer-related ischemic stroke (BCRS). METHODS Clinical features and laboratory findings were compared between BCRS group and breast cancer group without stroke, and further multivariate analyses were performed to predict independent risks factors for BCRS patients. A receiver operator characteristic (ROC) curve analysis was configured to estimate the diagnostic efficacy of each independent risk and the product of these risks and to obtain the optimal cut-off value of diagnosis, which was termed the BCRS Index. RESULTS BCRS patients had elevated plasma D-dimer and CA153 levels and platelet-to-lymphocyte ratio (PLR), as well as more patients received endocrine therapy (all p < 0.05). Moreover, multivariate analysis revealed that D-dimer levels (odds ratio [OR]: 1.002; 95% confidence interval [CI]: 1.001-1.003; p = 0.000), CA153 levels (OR: 1.005; 95% CI: 1.001-1.008; p = 0.007), PLR (OR: 1.010; 95% CI: 1.004-1.015; p = 0.001), and endocrine therapy (OR: 1.268; 95% CI: 1.087-1.479; p = 0.003) were identified as independent risks of BCRS. Furthermore, ROC analysis displayed that the product of risks had the best diagnostic efficacy, of which the area under the curve was 0.846 ± 0.28. The optimum cut-off point was 2.37 × 106/mL, which was termed the BCRS Index with higher diagnostic accuracy and validity. CONCLUSIONS Endocrine therapy, as well as elevated plasma D-dimer and CA153 levels and PLR values may be independent risks for BCRS. Furthermore, BCRS Index should be served as a novel specific biomarker for BCRS, which is useful to distinguish BCRS for clinicians.
Collapse
Affiliation(s)
- Xuemin Cheng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Qixiong Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Lizhi Lu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Chunyong Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Yunfei Wei
- Department of Neurology, The Second Affliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Dacheng Wang
- Department of Neurology, The Ninth Affiliated Hospital of Guangxi Medical University, Beihai, Guangxi, China
| | - Haihua Li
- Department of Neurology, Fusui County People's Hospital, Chongzuo, Guangxi, China
| | - Guohui Li
- Department of Neurology, Wuzhou Red Cross Hospital, Wuzhou, Guangxi, China
| | - Hongbin Liang
- Department of Neurology, Cenxi People's Hospital, Cenxi, Guangxi, China
| | - Shengyu Li
- Department of Neurology, Wuming County People's Hospital, Nanning, Guangxi, China
| | - Daobin Cheng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| |
Collapse
|
35
|
Clinical Characteristics and Risk Factors of Lung Cancer-Associated Acute Ischemic Stroke. BIOMED RESEARCH INTERNATIONAL 2019; 2019:6021037. [PMID: 31930131 PMCID: PMC6935791 DOI: 10.1155/2019/6021037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/07/2019] [Accepted: 10/16/2019] [Indexed: 12/24/2022]
Abstract
Objective To research the clinical characteristics and risk factors of lung cancer-associated acute ischemic stroke (LCA-AIS). Methods Patients diagnosed with LCA-AIS, simple lung cancer, and simple AIS were enrolled. The primary information, laboratory results, tumor histopathology, neurological deficits, and survival time of the patients were collected and analyzed. Results (1) In the LCA-AIS group, the pathology of 69.56% patients were adenocarcinoma, and the proportion of poorly differentiated patients was significantly more than that in moderately differentiated or highly differentiated. The number of stage IV lung cancer patients in the LCA-AIS group was significantly more common than in other stages. (2) 56.52% of patients with lung cancer were diagnosed before AIS, and the peak of AIS attack was 1–6 months after the diagnosis of lung cancer. (3) The independent risk factors of LCA-AIS were CYFRA-211 (OR 1.070; 95% confidence interval 1.005, 1.139; p = 0.035), TT (OR 1.275; 95% confidence interval 1.089, 1.493; p = 0.003), and Hct (OR 0.878; 95% confidence interval 0.779, 0.990; p = 0.034), making ROC curve, suggesting the area under the curve is 0.871. (4) The neurological deficit of patients in the LCA-AIS group was similar to the simple AIS group and could not be identified by the severity of neurological deficits. (5) The median survival time of LCA-AIS group patients was five months (95% confidence interval 3.796, 6.204). There were statistical differences in survival time between LCA-AIS group and simple AIS group patients (p < 0.001). Conclusions The interaction between lung cancer and AIS may shorten patients' life expectancy and worsen their quality of life.
Collapse
|
36
|
Potugari BR, Priyanka P, Komanapalli SD, Mercier RJ. Ovarian Cancer Presenting as Cryptogenic Stroke from Patent Foramen Ovale. Clin Med Res 2019; 17:97-101. [PMID: 31324738 PMCID: PMC6886892 DOI: 10.3121/cmr.2019.1444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 04/15/2019] [Accepted: 05/13/2019] [Indexed: 12/21/2022]
Abstract
A woman, aged 52 years, experienced severe headache, confusion, nausea, dizziness, and diplopia for three days. Magnetic resonance imaging of the brain showed multiple acute and subacute infarcts suggestive of embolic events. Dermatological examination was notable for splinter hemorrhages and macular patches on the fingernails and feet, respectively. Further diagnostic imaging of the chest and abdomen revealed pulmonary emboli and an ovarian mass with omental deposits and splenic infarcts. Fine-needle aspiration cytology and surgery confirmed a diagnosis of high-grade serous adenocarcinoma of the ovary with clear cell features. Extensive evaluation for malignancy should be considered on a case-by-case basis for patients with thromboembolic disease and an initial negative diagnostic evaluation for stroke. Consideration of patent foramen ovale closure is reasonable in patients with malignancy who are at risk for recurrent strokes.
Collapse
Affiliation(s)
- Bindu R Potugari
- Department of Internal Medicine, Marshfield Clinic, Marshfield, Wisconsin; Current affiliation: Oncology Fellow, St. Joseph Mercy Ann Arbor, Ypsilanti, Michigan
| | - Priyanka Priyanka
- Department of Internal Medicine, Marshfield Medical Center, Marshfield, Wisconsin; Current affiliation: Department of Internal Medicine, University of West Virginia, Morgantown, West Virginia
| | - Sarah D Komanapalli
- Department of Hospital Medicine, Marshfield Medical Center, Marshfield, Wisconsin
| | - Richard J Mercier
- Department of Oncology, Marshfield Medical Center, Marshfield, Wisconsin
| |
Collapse
|
37
|
Wilbers J, Sondag L, Mulder S, Siegerink B, van Dijk EJ. Cancer prevalence higher in stroke patients than in the general population: the Dutch String-of-Pearls Institute (PSI) Stroke study. Eur J Neurol 2019; 27:85-91. [PMID: 31299123 PMCID: PMC6916304 DOI: 10.1111/ene.14037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 07/08/2019] [Indexed: 01/14/2023]
Abstract
Background and purpose The aim of this study was to assess the prevalence of cancer and its characteristics in patients with ischemic stroke and to compare this with cancer prevalence in the general population. Methods This was a multicenter cohort study with 2736 patients presenting with ischemic stroke or transient ischemic attack. The prevalence of cancer was assessed by interview and verified by reviewing all medical records. In stroke patients with a history of cancer, we studied the subtype of cancer and its treatment characteristics. We used the national database of The Netherlands Cancer Registry to calculate population‐based age and sex cancer standardized prevalence ratios (SPRs) for patients with ischemic stroke. Results Cancer prevalence in ischemic stroke patients was 12%, corresponding to an SPR of 1.2 [95% confidence interval (CI), 1.0–1.3]. Increased SPRs were observed for cancer of the central nervous system (SPR, 18.2; 95% CI, 9.0–27.4), head and neck (SPR, 3.4; 95% CI, 2.3–4.6), lower respiratory tract (SPR, 2.4; 95% CI, 1.5–3.3) and urinary tract (SPR, 2.1; 95% CI, 1.4–2.9), but not for other cancer types. Cardiovascular risk factors, stroke etiology, treatment and outcome were not different between patients with or without a history of cancer. Conclusions In stroke patients, the prevalence of cancer, most prominently cancer of the central nervous system, head and neck, lower respiratory and urinary tract, was higher than in the general population. Medical treatment for the prevention of stroke in cancer survivors deserves further study.
Collapse
Affiliation(s)
- J Wilbers
- Center of Expertise for Cancer Survivorship, Radboud University Medical Center, Nijmegen, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Center for Neuroscience, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L Sondag
- Donders Institute for Brain, Cognition and Behaviour, Center for Neuroscience, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S Mulder
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - B Siegerink
- Department of Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Center for Stroke Research Berlin, Charite Universitätsmedizin Berlin, Berlin, Germany
| | - E J van Dijk
- Donders Institute for Brain, Cognition and Behaviour, Center for Neuroscience, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | |
Collapse
|
38
|
Chen Y, Qin QX, Qin C, Cheng DB, Huang CX, Wei YF, Liang ZJ. Specific Biomarkers of Prostate Cancer-Associated Ischemic Stroke: A Case-Control Study. Med Sci Monit 2019; 25:5536-5542. [PMID: 31383837 PMCID: PMC6679620 DOI: 10.12659/msm.917970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Ischemic stroke in cancer patients is associated with poor prognosis. However, the specific biomarkers of cancer-associated ischemic stroke (CaIS) have not been well defined. Material/Methods A retrospective study was conducted on PCaIS patients. Clinical data and laboratory and imaging findings were collected. Multivariable logistic regression analysis was used to analyze the independent risk factors for PCaIS. A multiple model combining the independent risk factors of PCaIS was developed using the receiver operating characteristic (ROC) and area under the ROC curve (AUC). Results A total of 83 PCaIS patients and 83 prostate cancer (PCa) patients were included. PCaIS patients had higher levels of D-dimer, neutrophil-to-lymphocyte ratio (NLR), and total prostate-specific antigen (T-PSA). In the multivariate analysis, D-dimer [OR=1.001, 95% CI: 1.00,1.00, P=0.002], NLR [OR=1.12, 95% CI: 1.04,1.22, P=0.005], and T-PSA [OR=6.275, 95% CI: 2.57,15.31, P<0.001] were independent risk factors of PCaIS. Additionally, the AUC of the multiple model of PCaIS was 0.815 (95% CI, 0.750–0.869), with sensitivity of 81.71% and specificity of 70.21%. Conclusions Elevated levels of D-dimer and T-PSA and increased NLR are independent risk factors of PCaIS. The multiple model of PCaIS can be a specific biomarker and is a reliable predictor of development of PCaIS.
Collapse
Affiliation(s)
- Ya Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Qi-Xiong Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Chao Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Dao-Bin Cheng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Chun-Xia Huang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Yun-Fei Wei
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| | - Zhi-Jian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
| |
Collapse
|
39
|
Wang F, Hu XY, Cui ZM, Fang XM, Dai Z, Wang T, Guo DL. Clinical and Imaging Characteristics of Malignant Tumor Concurrent with Stroke. Cancer Biother Radiopharm 2019; 34:504-510. [PMID: 31295003 DOI: 10.1089/cbr.2019.2853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objectives: The present study aimed to retrospectively compare the clinical and imaging characteristics and laboratory data of patients with malignant tumor concurrent with acute ischemic stroke (IS) and patients with cerebral infarction only, and to analyze the potential related risk factors. Method: A total of 126 patients with acute cerebral infarction concurrent with malignant tumor were collected and assigned to the malignant tumor group. In addition, 120 patients hospitalized for routine acute IS during the same period were randomly selected as the control group. Demographic data and common risk factors of cerebrovascular disease, laboratory data, and imaging characteristics in these two groups were compared. Results: In the malignant tumor group, the age of onset was relatively low, and the National Institutes of Health Stroke Scale score, 90 d recurrence rate, and fatality rate were higher than for those in the control group (p < 0.05). However, most patients had no traditional risk factors of stroke. Biochemical results revealed that the peripheral hemoglobin of patients with malignant tumor and cerebral infarction was lower than for those in the control group (p < 0.05). Furthermore, the levels of D-dimer, fibrinogen, tumor markers CA125, CA199, and carcinoembryonic antigen were significantly elevated, and the difference was statistically significant (p < 0.05). Magnetic resonance imaging results revealed that multiple intracranial infarcts were more common in patients in the malignant tumor group, and the difference was statistically significant compared with patients with cerebral infarction only (p < 0.05). Conclusion: Patients with cancer and IS had fewer traditional stroke risk factors but more anemia as well as higher D-dimer level, tumor marker rate, short-term mortality, and stroke recurrence rate. Furthermore, lower age of onset and other characteristics, including multiple intracranial infarcts, can be regarded as important characteristics of such patients.
Collapse
Affiliation(s)
- Feng Wang
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Xiao-Yun Hu
- Department of Radiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Zhi-Ming Cui
- Department of Radiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Xiang-Ming Fang
- Department of Radiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Zheng Dai
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Tao Wang
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Dao-Liu Guo
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| |
Collapse
|
40
|
Dardiotis E, Aloizou AM, Markoula S, Siokas V, Tsarouhas K, Tzanakakis G, Libra M, Kyritsis AP, Brotis AG, Aschner M, Gozes I, Bogdanos DP, Spandidos DA, Mitsias PD, Tsatsakis A. Cancer-associated stroke: Pathophysiology, detection and management (Review). Int J Oncol 2019; 54:779-796. [PMID: 30628661 PMCID: PMC6365034 DOI: 10.3892/ijo.2019.4669] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 12/28/2018] [Indexed: 12/15/2022] Open
Abstract
Numerous types of cancer have been shown to be associated with either ischemic or hemorrhagic stroke. In this review, the epidemiology and pathophysiology of stroke in cancer patients is discussed, while providing vital information on the diagnosis and management of patients with cancer and stroke. Cancer may mediate stroke pathophysiology either directly or via coagulation disorders that establish a state of hypercoagulation, as well as via infections. Cancer treatment options, such as chemotherapy, radiotherapy and surgery have all been shown to aggravate the risk of stroke as well. The clinical manifestation varies greatly depending upon the underlying cause; however, in general, cancer‑associated strokes tend to appear as multifocal in neuroimaging. Furthermore, several serum markers have been identified, such as high D‑Dimer levels and fibrin degradation products. Managing cancer patients with stroke is a delicate matter. The cancer should not be considered a contraindication in applying thrombolysis and recombinant tissue plasminogen activator (rTPA) administration, since the risk of hemorrhage in cancer patients has not been reported to be higher than that in the general population. Anticoagulation, on the contrary, should be carefully examined. Clinicians should weigh the benefits and risks of anticoagulation treatment for each patient individually; the new oral anticoagulants appear promising; however, low‑molecular‑weight heparin remains the first choice. On the whole, stroke is a serious and not a rare complication of malignancy. Clinicians should be adequately trained to handle these patients efficiently.
Collapse
Affiliation(s)
- Efthimios Dardiotis
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | - Athina-Maria Aloizou
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | - Sofia Markoula
- Department of Neurology, University Hospital of Ioannina, 45110 Ioannina
| | - Vasileios Siokas
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | | | - Georgios Tzanakakis
- Laboratory of Anatomy-Histology-Embryology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Massimo Libra
- Department of Biomedical and Biotechnological Sciences, Pathology and Oncology Section, University of Catania, 95124 Catania, Italy
| | | | - Alexandros G. Brotis
- Department of Neurosurgery, University of Thessaly, University Hospital of Larissa, 41100 Larissa, Greece
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Illana Gozes
- The Lily and Avraham Gildor Chair for the Investigation of Growth Factors, The Elton Laboratory for Molecular Neuroendocrinology, Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Sagol School of Neuroscience and Adams Super Center for Brain Studies, Tel Aviv University, Tel Aviv 69978, Israel
| | - Dimitrios P. Bogdanos
- Department of Rheumatology and Clinical Immunology, University General Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 40500 Larissa
- Cellular Immunotherapy and Molecular Immunodiagnostics, Biomedical Section, Centre for Research and Technology-Hellas (CERTH) - Institute for Research and Technology-Thessaly (IRETETH), 41222 Larissa
| | | | - Panayiotis D. Mitsias
- Department of Neurology, School of Medicine, University of Crete, 71003 Heraklion, Greece
- Comprehensive Stroke Center and Department of Neurology, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Aristidis Tsatsakis
- Laboratory of Toxicology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| |
Collapse
|
41
|
Nouh AM, Staff I, Finelli PF. Three Territory Sign: An MRI marker of malignancy-related ischemic stroke (Trousseau syndrome). Neurol Clin Pract 2019; 9:124-128. [PMID: 31041126 DOI: 10.1212/cpj.0000000000000603] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/17/2018] [Indexed: 11/15/2022]
Abstract
Background Multiple acute cerebral territory infarcts of undetermined origin are typically attributed to cardioembolism, most frequently atrial fibrillation. However, the importance of 3-territory involvement in association with malignancy is under-recognized. We sought to highlight the "Three Territory Sign" (TTS) (bilateral anterior and posterior circulation acute ischemic diffusion-weighted imaging [DWI] lesions), as a radiographic marker of stroke due to malignancy. Methods We conducted a single-center retrospective analysis of patients from January 2014 to January 2016, who suffered an acute ischemic stroke with MRI-DWI at our institution, yielding 64 patients with a known malignancy and 167 patients with atrial fibrillation, excluding patients with both to eliminate bias. All DWI images were reviewed for 3-, 2-, and 1-territory lesions. Chi-square test of proportion was used to test significance between the 2 groups. Results We found an association between the groups (malignancy vs atrial fibrillation) and the number of territory infarcts (p < 0.0001). Pairwise comparisons using the Holm p value adjustment showed no difference between 1- and 2-territory patterns (p = 0.465). However, the TTS was 6 times more likely observed within the malignancy cohort as compared to patients with atrial fibrillation (23.4% [n = 15] vs 3.5% [n = 6]) and was different from both 1-territory (p < 0.0001) and 2-territory patterns (p = 0.0032). Conclusion The TTS is a highly specific marker and 6 times more frequently observed in malignancy-related ischemic stroke than atrial fibrillation-related ischemic stroke. Evaluation for underlying malignancy in patients with the TTS is reasonable in patients with undetermined etiology.
Collapse
Affiliation(s)
- Amre M Nouh
- Department of Neurology (AN, PFF) and Department of Research (IS), Hartford Hospital, Hartford, CT
| | - Ilene Staff
- Department of Neurology (AN, PFF) and Department of Research (IS), Hartford Hospital, Hartford, CT
| | - Pasquale F Finelli
- Department of Neurology (AN, PFF) and Department of Research (IS), Hartford Hospital, Hartford, CT
| |
Collapse
|
42
|
Hung YS, Chen JS, Chen YY, Lu CH, Chang PH, Chou WC. Incidence, Risk Factors, and Outcomes of Arterial Thromboembolism in Patients with Pancreatic Cancer Following Palliative Chemotherapy. Cancers (Basel) 2018; 10:cancers10110432. [PMID: 30424491 PMCID: PMC6267556 DOI: 10.3390/cancers10110432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Few studies have explored the association between pancreatic cancer and arterial thromboembolism (aTE). METHODS A total of 838 consecutive patients receiving palliative chemotherapy for pancreatic cancer between 2010 and 2016 were retrospectively enrolled. The clinical characteristics of patients were analyzed to determine the incidence, risk factors, and survival outcome of aTE in patients with pancreatic cancer. RESULTS aTE occurred in 42 (5.0%) of 838 patients. Patients with aTE had a worse survival outcome than those without (5.1 months versus 7.8 months, hazard ratio 1.53, 95% confidence interval [CI]: 1.12⁻2.09). Stage IV disease, high aspartate transaminase level, and comorbidity with hypertension or atrial fibrillation were four independent predictors of aTE. A concise predictive model stratified patients into low (0⁻1 predictor), intermediate (2 predictors), and high (3⁻4 predictors) risk groups. The hazard ratios for the comparison of patients in intermediate and high risk groups with those in low risk group were 4.55 (95% CI: 2.31⁻8.98), and 13.3 (95% CI: 5.63⁻31.6), respectively. CONCLUSION Patients with pancreatic cancer undergoing palliative chemotherapy have an increased risk of aTE. A predictive model showed that patients presented with 3 or 4 predictors had the highest risk for developing aTE.
Collapse
Affiliation(s)
- Yu-Shin Hung
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan 333, Taiwan.
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan 333, Taiwan.
| | - Yen-Yang Chen
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung 833, Taiwan.
| | - Chang-Hsien Lu
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Chiayi, Chiayi 612, Taiwan.
| | - Pei-Hung Chang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Keelung, Keelung 204, Taiwan.
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan 333, Taiwan.
| |
Collapse
|
43
|
Selvik HA, Naess H, Kvistad CE. Intravenous Thrombolysis in Ischemic Stroke Patients With Active Cancer. Front Neurol 2018; 9:811. [PMID: 30337902 PMCID: PMC6180250 DOI: 10.3389/fneur.2018.00811] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 09/10/2018] [Indexed: 12/19/2022] Open
Abstract
Introduction: It has been difficult to state specific guidelines for IV-tPA use in cancer patients. Many of the randomized tPA-trials included too few patients with cancer or excluded patients with cancer entirely. In this report, we aimed to study the use of IV-tPA in patients with active cancer and acute ischemic stroke. We also investigated if the cancer patients who received IV-tPA experienced adverse events. Methods: All patients with ischemic stroke admitted to the Stroke Unit at Haukeland University Hospital were prospectively registered in the NORSTROKE database and every patient's medical record was searched for cancer diagnoses. Results: Of 1,646 patients admitted with ischemic stroke, 82 (5.0%) patients had active cancer. The total number of patients treated with IV-tPA was 16.2%. Five patients with stroke and active cancer were treated with IV-tPA (6.1%) and none suffered adverse events. Of the patients with no history of cancer, 261 (16.7%) were treated with IV-tPA and 3.8% experienced tPA-related adverse events. Conclusions: Few patients with active cancer receive thrombolysis for acute ischemic stroke. We report five cancer patients (three known and two occult) treated with IV-tPA for ischemic stroke without tPA-related adverse events.
Collapse
Affiliation(s)
- Henriette Aurora Selvik
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Halvor Naess
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | | |
Collapse
|