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Toi S, Higuchi E, Hosoya M, Arai S, Ishizuka K, Mizuno T, Hoshino T, Tsutsumi Y, Kitagawa K. Association of Transcranial Doppler Microembolic Signal With Short-Term Mortality in Acute Ischemic Stroke and Active Cancer. J Am Heart Assoc 2024; 13:e033634. [PMID: 39082410 DOI: 10.1161/jaha.123.033634] [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: 05/01/2024] [Accepted: 06/20/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND This study aimed to clarify the characteristics and survival prediction value of transcranial Doppler microembolic signals (MES) in patients with acute cerebral infarction and active cancer. METHODS AND RESULTS Between 2017 and 2022, 1089 cases of acute cerebral infarction were recorded within 7 days of disease onset. Among them, transcranial Doppler was successful in 33 patients who had active cancer, and these data were analyzed in this study. The primary outcomes were stroke recurrence and mortality at 3 months. The study population had the following characteristics [median (interquartile range)]: age, 70 years (63-78); body mass index, 21.6 (20-24), National Institutes of Health Stroke Scale 3 (1-6), and modified Rankin Scale score at discharge 1 (1-4). The most common cancer types were lung (24%), pancreatic (24%), and intestinal (18%). MES was present in 16 of 33 patients (48.5%). The presence and number of MES were significantly associated with the levels of D-dimer (P <0.001) and C-reactive protein (P=0.012). Moreover, the presence of MES was associated with multiple ischemic lesions and the 3-territory sign on magnetic resonance imaging. Of the 33 patients, 9 died at 3 months, and 1 had stroke recurrence. On Cox multivariate analysis, using the MES-negative group as a reference, the presence of MES was significantly associated with all-cause death (adjusted hazard ratio, 12.19 [95% CI, 1.45-216.85]; P=0.020). CONCLUSIONS In patients with acute ischemic stroke and active cancer, the presence of MES was associated with D-dimer and C-reactive protein levels and multiple and 3-territory ischemic lesions, and was predictive of short-term survival.
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Affiliation(s)
- Sono Toi
- Department of Medicine Tokyo Women's Medical University Adachi Medical Center Tokyo Japan
- Department of Neurology Tokyo Women's Medical University Tokyo Japan
| | - Eiko Higuchi
- Department of Neurology Tokyo Women's Medical University Tokyo Japan
| | - Megumi Hosoya
- Department of Neurology Tokyo Women's Medical University Tokyo Japan
| | - Satoko Arai
- Department of Neurology Tokyo Women's Medical University Tokyo Japan
| | - Kentaro Ishizuka
- Department of Neurology Tokyo Women's Medical University Tokyo Japan
| | - Takafumi Mizuno
- Department of Neurology Tokyo Women's Medical University Tokyo Japan
| | - Takao Hoshino
- Department of Neurology Tokyo Women's Medical University Tokyo Japan
| | - Yukiko Tsutsumi
- Department of Neurology Tokyo Women's Medical University Tokyo Japan
- International St Luke hospital Tokyo Japan
| | - Kazuo Kitagawa
- Department of Medicine Tokyo Women's Medical University Adachi Medical Center Tokyo Japan
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Gwag HB, Ko NG, Jin M. Impact of an expanded reimbursement policy on utilization of implantable loop recorders in patients with cryptogenic stroke in Korea. Korean J Intern Med 2024; 39:469-476. [PMID: 38632895 PMCID: PMC11076896 DOI: 10.3904/kjim.2023.479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND/AIMS The reimbursement policy for cryptogenic stroke (CS) was expanded in November 2018 from recurrent strokes to the first stroke episode. No reports have demonstrated whether this policy change has affected trends in implantable loop recorder (ILR) utilization. METHODS We identified patients who received an ILR implant using the Korea Health Insurance Review and Assessment Service database between July 2016 and October 2021. Patients meeting all the following criteria were considered to have CS indication: 1) prior stroke history, 2) no previous history of atrial fibrillation or flutter (AF/AFL), and 3) no maintenance of oral anticoagulant for ≥4 weeks within a year before ILR implant. AF/AFL diagnosed within 3 years after ILR implant or before ILR removal was considered ILR-driven. RESULTS Among 3,056 patients, 1,001 (32.8%) had CS indications. The total ILR implant number gradually increased for both CS and non-CS indications and the number of CS indication significantly increased after implementing the expanded reimbursement policy. The detection rate for AF/AFL was 26.3% in CS patients over 3 years, which was significantly higher in patients implanted with an ILR within 2 months after stroke than those implanted later. CONCLUSION The expanded coverage policy for CS had a significant impact on the number of ILR implantation for CS indication. The diagnostic yield of ILR for AF/AFL detection seems better when ILR is implanted within 2 months than later. Further investigation is needed to demonstrate other clinical benefits and the optimal ILR implantation timing.
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Affiliation(s)
- Hye Bin Gwag
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon,
Korea
| | - Nak Gyeong Ko
- Department of Research and Support, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon,
Korea
| | - Mihyeon Jin
- Department of Research and Support, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon,
Korea
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Kawano T, Mackman N. Cancer patients and ischemic stroke. Thromb Res 2024; 237:155-162. [PMID: 38603819 DOI: 10.1016/j.thromres.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/26/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024]
Abstract
Patients with cancer have an increased risk of ischemic stroke compared to the general population. Additionally, these patients have a worse prognosis compared to stroke patients without cancer. Activation of coagulation appears to play a key role in the pathophysiology of ischemic stroke in patients with cancer. However, the underlying mechanisms remain unknown. Moreover, we do not have a way to identify cancer patients with a high risk of stroke and cannot develop prevention strategies. Therefore, there is an urgent need for neurologists and oncologists to develop screening and prevention strategies for stroke in patients with cancer. In this review, we summarize the characteristics of cancer patients at a high risk of stroke, the predictors for the development of stroke and survival in cancer patients, and possible treatments.
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Affiliation(s)
- Tomohiro Kawano
- Department of Neurology, Kano general hospital, Osaka, Japan
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Costamagna G, Hottinger AF, Milionis H, Salerno A, Strambo D, Livio F, Navi BB, Michel P. Acute ischaemic stroke in active cancer versus non-cancer patients: stroke characteristics, mechanisms and clinical outcomes. Eur J Neurol 2024; 31:e16200. [PMID: 38235924 PMCID: PMC11235609 DOI: 10.1111/ene.16200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND PURPOSE Demographics, clinical characteristics, stroke mechanisms and long-term outcomes were compared between acute ischaemic stroke (AIS) patients with active cancer (AC) versus non-cancer patients. METHODS Using data from 2003 to 2021 in the Acute STroke Registry and Analysis of Lausanne, a retrospective cohort study was performed comparing patients with AC, including previously known and newly diagnosed cancers, with non-cancer patients. Patients with inactive cancer were excluded. Outcomes were the modified Rankin Scale (mRS) score at 3 months, death and cerebrovascular recurrences at 12 months before and after propensity score matching. RESULTS Amongst 6686 patients with AIS, 1065 (15.9%) had a history of cancer. After excluding 700 (10.4%) patients with inactive cancer, there were 365 (5.5%) patients with AC and 5621 (84%) non-cancer AIS patients. Amongst AC patients, 154 (42.2%) strokes were classified as cancer related. In multivariable analysis, patients with AC were older (adjusted odds ratio [aOR] 1.02, 95% confidence interval [CI] 1.00-1.03), had fewer vascular risk factors and were 48% less likely to receive reperfusion therapies (aOR 0.52, 95% CI 0.35-0.76). Three-month mRS scores were not different in AC patients (aOR 2.18, 95% CI 0.96-5.00). At 12 months, death (adjusted hazard ratio 1.91, 95% CI 1.50-2.43) and risk of cerebrovascular recurrence (sub-distribution hazard ratio 1.68, 95% CI 1.22-2.31) before and after propensity score matching were higher in AC patients. CONCLUSIONS In a large institutional registry spanning nearly two decades, AIS patients with AC had less past cerebrovascular disease but a higher 1-year risk of subsequent death and cerebrovascular recurrence compared to non-cancer patients. Antithrombotic medications at discharge may reduce this risk in AC patients.
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Affiliation(s)
- Gianluca Costamagna
- Stroke Center, Neurology Service, Department of Clinical NeurosciencesLausanne University Hospital and University of LausanneLausanneSwitzerland
- Dino Ferrari Centre, Department of Pathophysiology and Transplantation (DEPT)University of MilanMilanItaly
| | - Andreas F. Hottinger
- Lundin and Family Brain Tumor Research Center, Services of Neurology and OncologyLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Haralampos Milionis
- First Department of Internal Medicine, Medical SchoolUniversity of IoanninaIoanninaGreece
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical NeurosciencesLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Department of Clinical NeurosciencesLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Francoise Livio
- Service of Clinical PharmacologyLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Babak B. Navi
- Feil Family Brain and Mind Research Institute and Department of NeurologyWeill Cornell MedicineNew York CityNew YorkUSA
- Department of NeurologyMemorial Sloan Kettering Cancer CenterNew York CityNew YorkUSA
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical NeurosciencesLausanne University Hospital and University of LausanneLausanneSwitzerland
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Costamagna G, Navi BB, Beyeler M, Hottinger AF, Alberio L, Michel P. Ischemic Stroke in Cancer: Mechanisms, Biomarkers, and Implications for Treatment. Semin Thromb Hemost 2024; 50:342-359. [PMID: 37506734 DOI: 10.1055/s-0043-1771270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Ischemic stroke is an important cause of morbidity and mortality in cancer patients. The underlying mechanisms linking cancer and stroke are not completely understood. Long-standing and more recent evidence suggests that cancer-associated prothrombotic states, along with treatment-related vascular toxicity, such as with chemotherapy and immunotherapy, contribute to an increased risk of ischemic stroke in cancer patients. Novel biomarkers, including coagulation, platelet and endothelial markers, cell-free DNA, and extracellular vesicles are being investigated for their potential to improve risk stratification and patient selection for clinical trials and to help guide personalized antithrombotic strategies. Treatment of cancer-related stroke poses unique challenges, including the need to balance the risk of recurrent stroke and other thromboembolic events with that of bleeding associated with antithrombotic therapy. In addition, how and when to restart cancer treatment after stroke remains unclear. In this review, we summarize current knowledge on the mechanisms underlying ischemic stroke in cancer, propose an etiological classification system unique to cancer-related stroke to help guide patient characterization, provide an overview of promising biomarkers and their clinical utility, and discuss the current state of evidence-based management strategies for cancer-related stroke. Ultimately, a personalized approach to stroke prevention and treatment is required in cancer patients, considering both the underlying cancer biology and the individual patient's risk profile.
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Affiliation(s)
- Gianluca Costamagna
- Stroke Unit, Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas F Hottinger
- Services of Neurology and Oncology, Lundin Family Brain Tumor Research Center, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Hematology Central Laboratory, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Stroke Center, Neurology Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Sakurai R, Gon Y, Shimada Y, Okazaki S, Todo K, Sasaki T, Mochizuki H. Association between the controlling nutritional status score and outcomes in ischemic stroke patients with active cancer. J Clin Neurosci 2024; 120:170-174. [PMID: 38245980 DOI: 10.1016/j.jocn.2024.01.011] [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: 11/08/2023] [Revised: 12/20/2023] [Accepted: 01/08/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND The effect of nutritional status on survival in ischemic stroke patients with active cancer remains unclear. METHODS This study retrospectively evaluated ischemic stroke patients with active cancer admitted to a university hospital in Japan between 2006 and 2016. Patients were followed for 2 years after stroke. The controlling nutritional status (CONUT) score was used to classify undernutrition degree into 4 groups: normal, light, moderate, and severe. Survival rates were compared using the Kaplan-Meier method. Hazard ratio (HR) and 95 % confidence intervals (CIs) for mortality were calculated using Cox regression models. RESULTS A total of 158 patients (31 % women; median age: 71 years) were analyzed. Of these, 47 % had distant metastasis. The median (interquartile range) National Institute of Health Stroke Scale and CONUT scores were 4 (1-10) and 5 (3-7), respectively. Kaplan-Meier curve indicated that patients with poorer nutritional status had worse outcomes (overall log-rank test, p < 0.001). The univariable Cox regression analysis showed that the HR (95 % CI) for the light, moderate, and severe groups were 1.14 (0.45-2.86), 3.01 (1.27-7.12), and 2.94 (1.10-7.84), respectively. This statistical significance did not persist after adjustment for potential confounders (HR [95 % CI] for the light, moderate, and severe groups were 0.95 [0.36-2.49], 1.56 [0.57-4.28], and 1.34 [0.37-4.92], respectively). Past stroke, distant metastasis, and plasma D-dimer levels on admission were independent predictors of prognosis. CONCLUSIONS This single-center, retrospective study suggests that nutritional status serves as a prognostic indicator for ischemic stroke patients with active cancer. However, the effect is not statistically independent.
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Affiliation(s)
- Rei Sakurai
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasufumi Gon
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Yuki Shimada
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
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Gon Y, Sakaguchi M, Yamagami H, Abe S, Hashimoto H, Ohara N, Takahashi D, Abe Y, Takahashi T, Kitano T, Okazaki S, Todo K, Sasaki T, Hattori S, Mochizuki H. Predictors of Survival in Patients With Ischemic Stroke and Active Cancer: A Prospective, Multicenter, Observational Study. J Am Heart Assoc 2023; 12:e029618. [PMID: 37489755 PMCID: PMC10493000 DOI: 10.1161/jaha.123.029618] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/27/2023] [Indexed: 07/26/2023]
Abstract
Background Limited data exist on the prognostic factors for patients with ischemic stroke and active cancer. Methods and Results We conducted a prospective, multicenter, observational study in Japan, including patients with acute ischemic stroke and active cancer, to investigate the prognostic factors. We followed up the patients for 1 year after stroke onset. The patients were divided into 2 groups according to cryptogenic stroke and known causes (small-vessel occlusion, large-artery atherosclerosis, cardioembolism, and other determined cause), and survival was compared. The hazard ratios (HRs) and 95% CIs for mortality were calculated using Cox regression models. We identified 135 eligible patients (39% women; median age, 75 years). Of these patients, 51% had distant metastasis. A total of 65 (48%) and 70 (52%) patients had cryptogenic stroke and known causes, respectively. Patients with cryptogenic stroke had significantly shorter survival than those with known causes (HR [95% CI], 3.11 [1.82-5.32]). The multivariable Cox regression analysis revealed that distant metastasis, plasma D-dimer levels, venous thromboembolism (either deep venous thrombosis or pulmonary embolism) complications at stroke onset were independent predictors of mortality after adjusting for potential confounders. Cryptogenic stroke was associated with prognosis in univariable analysis but was not significant in multivariable analysis. The plasma D-dimer levels stratified the prognosis of patients with ischemic stroke and active cancer. Conclusions The prognosis of patients with acute ischemic stroke and active cancer varied considerably depending on stroke mechanism, distant metastasis, and coagulation abnormalities. The present study confirmed that coagulation abnormalities were crucial in determining the prognosis of such patients.
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Affiliation(s)
- Yasufumi Gon
- Department of NeurologyOsaka University Graduate School MedicineOsakaJapan
| | - Manabu Sakaguchi
- Department of NeurologyOsaka University Graduate School MedicineOsakaJapan
- Department of NeurologyOsaka General Medical CenterOsakaJapan
| | - Hiroshi Yamagami
- Department of NeurologyNational Hospital Organization Osaka National HospitalOsakaJapan
| | - Soichiro Abe
- Department of NeurologyNational Cerebral and Cardiovascular CenterOsakaJapan
| | | | - Nobuyuki Ohara
- Department of NeurologyKobe City Medical Center General HospitalHyogoJapan
| | - Daisuke Takahashi
- Department of NeurologyNational Hospital Organization Osaka Minami Medical CenterOsakaJapan
| | - Yuko Abe
- Department of NeurologyYodogawa Christian HospitalOsakaJapan
| | | | - Takaya Kitano
- Department of NeurologyOsaka University Graduate School MedicineOsakaJapan
| | - Shuhei Okazaki
- Department of NeurologyOsaka University Graduate School MedicineOsakaJapan
| | - Kenichi Todo
- Department of NeurologyOsaka University Graduate School MedicineOsakaJapan
| | - Tsutomu Sasaki
- Department of NeurologyOsaka University Graduate School MedicineOsakaJapan
| | - Satoshi Hattori
- Department of Integrated Medicine, Biomedical StatisticsOsaka University Graduate School of MedicineOsakaJapan
| | - Hideki Mochizuki
- Department of NeurologyOsaka University Graduate School MedicineOsakaJapan
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Aloizou AM, Palaiodimou L, Aloizou D, Dardiotis E, Gold R, Tsivgoulis G, Krogias C. Acute reperfusion treatment and secondary prevention of cancer-related stroke: comprehensive overview and proposal of clinical algorithm. Ther Adv Neurol Disord 2023; 16:17562864231180717. [PMID: 37342814 PMCID: PMC10278431 DOI: 10.1177/17562864231180717] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/20/2023] [Indexed: 06/23/2023] Open
Abstract
Cancer-related stroke (CRS), referring to ischemic stroke occurring in cancer patients without other clear etiology, represents a clinical challenge, as it is associated with unfavorable clinical outcomes including high rates of recurrence and mortality. There are scarce international recommendations and limited consensus statements on CRS management. For this comprehensive overview, the available studies/reviews/meta-analyses on the use of acute reperfusion and secondary prevention treatments for cancer patients with ischemic stroke, focusing on antithrombotic agents, were collected and summarized. A practical management algorithm was designed per the available data. In short, acute reperfusion in the form of intravenous thrombolysis and mechanical thrombectomy appears to be safe in CRS and can be considered for eligible patients, though the functional outcomes are often poor, and mostly defined by the preexisting condition. Many patients carry indications for anticoagulation, in which case vitamin K antagonists are not preferred, while low-molecular weight heparins remain the treatment of choice; direct oral anticoagulants can be alternatively considered but are contraindicated for gastrointestinal malignancies. For patients without clear anticoagulation indications, no net benefit for anticoagulation compared to aspirin has been shown. Other targeted treatment options should be evaluated in an individualized approach, alongside the appropriate management of conventional cerebrovascular risk factors. Oncological treatment should be swiftly initiated/continued. In conclusion, acute CRS remains a clinical challenge, with many patients suffering recurrent stroke, despite preventive measures. More randomized-controlled clinical trials are urgently needed to pinpoint the most effective management options for this subset of stroke patients.
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Affiliation(s)
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, ‘Attikon’ University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitra Aloizou
- Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
| | - Efthimios Dardiotis
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, ‘Attikon’ University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Christos Krogias
- Department of Neurology, Evangelisches Krankenhaus Herne, Ruhr University Bochum, Bochum, Germany
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Costamagna G, Hottinger A, Milionis H, Lambrou D, Salerno A, Strambo D, Livio F, Navi BB, Michel P. Clinical and Demographic Characteristics, Mechanisms, and Outcomes in Patients With Acute Ischemic Stroke and Newly Diagnosed or Known Active Cancer. Neurology 2023; 100:e2477-e2489. [PMID: 37094994 PMCID: PMC10264053 DOI: 10.1212/wnl.0000000000207341] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/09/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with a new diagnosis of cancer carry an increased risk of acute ischemic stroke (AIS), and this risk varies depending on age, cancer type, stage, and time from diagnosis. Whether patients with AIS with a new diagnosis of neoplasm represent a distinct subset from those with a previously known active malignancy remains unclear. We aimed to estimate the rate of stroke in patients with newly diagnosed cancer (NC) and previously known active cancer (KC) and to compare the demographic and clinical features, stroke mechanisms, and long-term outcomes between groups. METHODS Using 2003-2021 data from the Acute STroke Registry and Analysis of Lausanne registry, we compared patients with KC with patients with NC (cancer identified during AIS hospitalization or within the following 12 months). Patients with inactive and no history of cancer were excluded. Outcomes were the modified Rankin scale (mRS) score at 3 months and mortality and recurrent stroke at 12 months. We used multivariable regression analyses to compare outcomes between groups while adjusting for important prognostic variables. RESULTS Among 6,686 patients with AIS, 362 (5.4%) had active cancer (AC), including 102 (1.5%) with NC. Gastrointestinal and genitourinary cancers were the most frequent cancer types. Among all patients with AC, 152 (42.5%) AISs were classified as cancer related, with nearly half of these cases attributed to hypercoagulability. In multivariable analysis, patients with NC had less prestroke disability (adjusted odds ratio [aOR] 0.62, 95% CI 0.44-0.86) and fewer prior stroke/transient ischemic attack events (aOR 0.43, 95% CI 0.21-0.88) than patients with KC. Three-month mRS scores were similar between cancer groups (aOR 1.27, 95% CI 0.65-2.49) and were predominantly driven by the presence of newly diagnosed brain metastases (aOR 7.22, 95% CI 1.49-43.17) and metastatic cancer (aOR 2.19, 95% CI 1.22-3.97). At 12 months, mortality risk was higher in patients with NC vs patients with KC (hazard ratio [HR] 2.11, 95% CI 1.38-3.21), while recurrent stroke risk was similar between groups (adjusted HR 1.27, 95% CI 0.67-2.43). DISCUSSION In a comprehensive institutional registry spanning nearly 2 decades, 5.4% of patients with AIS had AC, a quarter of which were diagnosed during or within 12 months after the index stroke hospitalization. Patients with NC had less disability and prior cerebrovascular disease, but a higher 1-year risk of subsequent death than patients with KC.
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Affiliation(s)
- Gianluca Costamagna
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Andreas Hottinger
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Haralampos Milionis
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dimitris Lambrou
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexander Salerno
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Davide Strambo
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Françoise Livio
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Babak Benjamin Navi
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Patrik Michel
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
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Choi BK, Lee JS, Kim HR, Kim HS, Jung YH, Park YR. Bleeding risk and mortality according to antithrombotic agents' exposure in cancer-related stroke patients: nationwide population-based cohort study in South Korea. BMC Neurol 2023; 23:187. [PMID: 37161360 PMCID: PMC10169453 DOI: 10.1186/s12883-023-03208-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/14/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Ischemic stroke with active cancer is thought to have a unique mechanism compared to conventional stroke etiologies. There is no gold standard guideline for secondary prevention in patients with cancer-related stroke, hence, adequate type of antithrombotic agent for treatment is controversial. METHODS Subjects who were enrolled in National Health Insurance System Customized Research data during the period between 2010 and 2015 were observed until 2019. Subject diagnosed with ischemic stroke within six months before and 12 months after a cancer diagnosis was defined as cancer-related stroke patient. To solve immeasurable time bias, the drug exposure evaluation was divided into daily units, and each person-day was classified as four groups: antiplatelet, anticoagulant, both types, and unexposed to antithrombotic drugs. To investigate bleeding risk and mortality, Cox proportional hazards regression model with time-dependent covariates were used. RESULTS Two thousand two hundred eighty-five subjects with cancer-related stroke were followed and analyzed. A group with anticoagulation showed high estimated hazard ratios (HRs) of all bleeding events compared to a group with antiplatelet (major bleeding HR, 1.35; 95% confidence interval [CI], 1.20-1.52; p < 0.001). And the result was also similar in the combination group (major bleeding HR, 1.54; 95% CI, 1.13-2.09; p = 0.006). The combination group also showed increased mortality HR compared to antiplatelet group (HR, 1.72; 95% CI, 1.47-2.00; p < 0.001). CONCLUSIONS Bleeding risk increased in the anticoagulant-exposed group compared to antiplatelet-exposed group in cancer-related stroke patients. Thus, this result should be considered when selecting a secondary prevention drug.
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Affiliation(s)
- Bo Kyu Choi
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, 05505, Korea
| | - Hae Reong Kim
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Han Sang Kim
- Yonsei Cancer Center, Division of Medical Oncology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Graduate School of Medical Science, Severance Biomedical Science Institute, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Korea
| | - Yo Han Jung
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Yu Rang Park
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea.
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11
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Waseem A, Rashid S, Rashid K, Khan MA, Khan R, Haque R, Seth P, Raza SS. Insight into the transcription factors regulating Ischemic Stroke and Glioma in Response to Shared Stimuli. Semin Cancer Biol 2023; 92:102-127. [PMID: 37054904 DOI: 10.1016/j.semcancer.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/28/2023] [Accepted: 04/09/2023] [Indexed: 04/15/2023]
Abstract
Cerebral ischemic stroke and glioma are the two leading causes of patient mortality globally. Despite physiological variations, 1 in 10 people who have an ischemic stroke go on to develop brain cancer, most notably gliomas. In addition, glioma treatments have also been shown to increase the risk of ischemic strokes. Stroke occurs more frequently in cancer patients than in the general population, according to traditional literature. Unbelievably, these events share multiple pathways, but the precise mechanism underlying their co-occurrence remains unknown. Transcription factors (TFs), the main components of gene expression programmes, finally determine the fate of cells and homeostasis. Both ischemic stroke and glioma exhibit aberrant expression of a large number of TFs, which are strongly linked to the pathophysiology and progression of both diseases. The precise genomic binding locations of TFs and how TF binding ultimately relates to transcriptional regulation remain elusive despite a strong interest in understanding how TFs regulate gene expression in both stroke and glioma. As a result, the importance of continuing efforts to understand TF-mediated gene regulation is highlighted in this review, along with some of the primary shared events in stroke and glioma.
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Affiliation(s)
- Arshi Waseem
- Laboratory for Stem Cell & Restorative Neurology, Department of Biotechnology, Era's Lucknow Medical College and Hospital, Era University, Sarfarazganj, Lucknow-226003, India
| | - Sumaiya Rashid
- Department of Pharmacology & Toxicology, College of Pharmacy, Prince Sattam Bin Abdulaziz University, P.O. Box 173, Al-Kharj 11942, Saudi Arabia
| | - Khalid Rashid
- Department of Cancer Biology, Vontz Center for Molecular Studies, Cincinnati, OH 45267-0521
| | | | - Rehan Khan
- Chemical Biology Unit, Institute of Nano Science and Technology, Knowledge City,Mohali, Punjab 140306, India
| | - Rizwanul Haque
- Department of Biotechnology, Central University of South Bihar, Gaya -824236, India
| | - Pankaj Seth
- Molecular and Cellular Neuroscience, Neurovirology Section, National Brain Research Centre, Manesar, Haryana-122052, India
| | - Syed Shadab Raza
- Laboratory for Stem Cell & Restorative Neurology, Department of Biotechnology, Era's Lucknow Medical College and Hospital, Era University, Sarfarazganj, Lucknow-226003, India; Department of Stem Cell Biology and Regenerative Medicine, Era's Lucknow Medical College Hospital, Era University, Sarfarazganj, Lucknow-226003, India
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12
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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.
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13
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Kelly DM, Feld J, Rothwell PM, Reinecke H, Koeppe J. Admission Rates, Time Trends, Risk Factors, and Outcomes of Ischemic and Hemorrhagic Stroke From German Nationwide Data. Neurology 2022; 99:e2593-e2604. [PMID: 36332988 PMCID: PMC9754650 DOI: 10.1212/wnl.0000000000201259] [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: 03/31/2022] [Accepted: 08/01/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In the past decade, there have been major improvements in the control of risk factors, acute stroke therapies, and rehabilitation after the availability of high-quality evidence and guidelines on best practices in the acute phase. In this changing landscape, we aimed to investigate the stroke admission rates, time trends, risk factors, and outcomes during the period of 2014-2019 using German nationwide data. METHODS We obtained data of all acute stroke hospitalizations by the Federal Statistical Office. All hospitalized cases of adults (age 18 years or older) with acute stroke from the years 2014-2019 were analyzed regarding time trends, risk factors, treatments, morbidity, and in-hospital mortality according to stroke subtype (all-cause/ischemic/hemorrhagic). RESULTS Between 2014 and 2019, overall stroke hospitalizations in adults (median age = 76 years, [IQR: 65-83 years]) initially increased from 306,425 in 2014 to peak at 318,849 in 2017 before falling to again to 312,692 in 2019, whereas percentage stroke hospitalizations that resulted in death remained stable during this period at 8.5% in 2014 and 8.6% in 2019. In a multivariate model of 1,882,930 cases, the strongest predictors of in-hospital stroke mortality were hemorrhagic subtype (adjusted OR [aOR] = 3.06, 95% CI 3.02-3.10; p < 0.001), cancer (aOR = 2.11, 2.06-2.16; p < 0.001), congestive heart failure (aOR = 1.70, 1.67-1.73; p < 0.001), and lower extremity arterial disease (aOR = 1.76, 1.67-1.84; p < 0.001). DISCUSSION Despite recent advances in acute stroke care over the past decade, the percentage of stroke hospitalizations resulting in death remained unchanged. Further research is needed to determine how best to optimize stroke care pathways for multimorbid patients.
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Affiliation(s)
- Dearbhla M Kelly
- From the J Philip Kistler Stroke Research Center (D.M.K.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114 USA; Institute of Biostatistics and Clinical Research (J.F., J.K.), University of Muenster, Germany; Wolfson Centre for the Prevention of Stroke and Dementia (D.M.K., P.M.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom; and Department of Cardiology I: Coronary and Peripheral Vascular Disease (H.R.), Heart Failure, University Hospital Muenster, Germany.
| | - Jannik Feld
- From the J Philip Kistler Stroke Research Center (D.M.K.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114 USA; Institute of Biostatistics and Clinical Research (J.F., J.K.), University of Muenster, Germany; Wolfson Centre for the Prevention of Stroke and Dementia (D.M.K., P.M.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom; and Department of Cardiology I: Coronary and Peripheral Vascular Disease (H.R.), Heart Failure, University Hospital Muenster, Germany
| | - Peter M Rothwell
- From the J Philip Kistler Stroke Research Center (D.M.K.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114 USA; Institute of Biostatistics and Clinical Research (J.F., J.K.), University of Muenster, Germany; Wolfson Centre for the Prevention of Stroke and Dementia (D.M.K., P.M.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom; and Department of Cardiology I: Coronary and Peripheral Vascular Disease (H.R.), Heart Failure, University Hospital Muenster, Germany
| | - Holger Reinecke
- From the J Philip Kistler Stroke Research Center (D.M.K.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114 USA; Institute of Biostatistics and Clinical Research (J.F., J.K.), University of Muenster, Germany; Wolfson Centre for the Prevention of Stroke and Dementia (D.M.K., P.M.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom; and Department of Cardiology I: Coronary and Peripheral Vascular Disease (H.R.), Heart Failure, University Hospital Muenster, Germany
| | - Jeanette Koeppe
- From the J Philip Kistler Stroke Research Center (D.M.K.), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114 USA; Institute of Biostatistics and Clinical Research (J.F., J.K.), University of Muenster, Germany; Wolfson Centre for the Prevention of Stroke and Dementia (D.M.K., P.M.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom; and Department of Cardiology I: Coronary and Peripheral Vascular Disease (H.R.), Heart Failure, University Hospital Muenster, Germany
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Tanimura J, Yamamoto T, Hashimoto T. Clinical features and prognostic factors in patients with cancer-associated multiple ischemic stroke: A retrospective observational study. J Stroke Cerebrovasc Dis 2022; 31:106813. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 09/11/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022] Open
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Rakhimova I, Semenova Y, Khaibullin T, Kuanysheva A, Kovalchuk V, Abdrakhmanov A. Cryptogenic Stroke and Embolic Stroke of Undetermined Source: Risk Factors and Approaches for Detection of Atrial Fibrillation. Curr Cardiol Rev 2022; 18:e211221199213. [PMID: 34939547 PMCID: PMC9893140 DOI: 10.2174/1573403x18666211221145714] [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: 06/15/2021] [Revised: 08/17/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Stroke is a problem worldwide because of its high mortality and disability rates. Almost 90% of strokes are ischemic, and more than half of the deaths are caused by an ischemic stroke. Most risk factors for stroke are manageable so that it can be avoided with proper prevention. Despite the success in determining the causes of stroke in recent years, selectively, the "culprit" causing stroke remains unsolved. In such cases, a diagnosis of undetermined etiology (cryptogenic stroke) or embolic stroke of undetermined source (ESUS) is generated, resulting the prevention of a recurrent cerebrovascular occurrence impossible. Atrial fibrillation (AF) can be a cause of stroke by causing blood clots in the chambers of the heart. PURPOSE The aim was to determine the optimal method of heart rate monitoring in patients with ischemic stroke, as methods and approaches for detecting AF are very diverse, but there is still no single opinion, which would be universal. PROCEDURES In our review, we consider epidemiology, risk factors for the stroke of undetermined etiology, as well as analytical methods for detecting heart rhythm disturbances in this category of patients. FINDINGS Atrial fibrillation (AF) is detected by thorough monitoring of heart rate of patients with cryptogenic stroke and ESUS can be diagnosed in up to 46% of patients. . CONCLUSION After AF detection, consideration should be given to prescribing anticoagulants, instead of antiplatelet agents, for the secondary prevention of stroke.
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Affiliation(s)
- Idaliya Rakhimova
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Yuliya Semenova
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Talgat Khaibullin
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Anargul Kuanysheva
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Vitalii Kovalchuk
- Department of Semashko City Hospital, Saint Petersburg, Russian Federation
| | - Ayan Abdrakhmanov
- National Research Cardiac Surgery Center, Nur-Sultan 010000, Kazakhstan
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Abstract
Objective We assessed the relationship between the levels of serum alkaline phosphatase, which is often increased with biliary obstruction and bone metastasis, and active cancer in patients with cryptogenic stroke. Methods Serum alkaline phosphatase levels in patients with cryptogenic stroke sampled upon admission were measured using the Japan Society of Clinical Chemistry method used in Japan. Active cancer was defined as a new diagnosis, treatment, progression, or recurrence within six months before admission or metastatic cancer. Multivariate logistic regression analyses were performed to explore the relationship between serum alkaline phosphatase and active cancer in these patients. Results Among the 249 patients classified as having cryptogenic stroke, 64 had active cancer. Patients with cryptogenic stroke with active cancer had significantly higher serum alkaline phosphatase levels (486±497 vs. 259±88.2 U/L; p<0.001) than those without cancer. Multivariate logistic analysis revealed that serum alkaline phosphatase levels ≥286 U/L were associated with cryptogenic stroke with active cancer [odds ratio (OR), 2.669, 95% confidence interval (CI), 1.291-5.517; p=0.008] independent of age ≤70 years old (OR, 3.303, 95% CI, 1.569-6.994; p=0.002), male sex (OR, 0.806, 95% CI, 0.380-1.710; p=0.573), and serum D-dimer levels ≥2.6 μg/mL (OR, 18.78, 95% CI, 8.130-43.40; p<0.001). Conclusion In patients with cryptogenic stroke, high serum alkaline phosphatase levels may be related to active cancer.
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Affiliation(s)
- Tesseki Izumi
- Department of Neurology, Nara Medical University, Japan
| | | | | | - Maki Ozaki
- Department of Neurology, Nara Medical University, Japan
| | - Kazuma Sugie
- Department of Neurology, Nara Medical University, Japan
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17
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Nam KW, Kwon HM, Lee YS. Effects of intracranial atherosclerosis and atrial fibrillation on the prognosis of ischemic stroke with active cancer. PLoS One 2021; 16:e0259627. [PMID: 34739530 PMCID: PMC8570487 DOI: 10.1371/journal.pone.0259627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/25/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In ischemic stroke patients with active cancer, cryptogenic stroke has worse prognosis than stroke by conventional mechanisms. However, the individual effects of intracranial atherosclerosis (ICAS) or atrial fibrillation (AF) on the prognosis of these patients have not been studied. AIMS Therefore, we aimed to investigate the effects of ICAS and AF on the prognosis of ischemic stroke patients with active cancer. METHODS We included ischemic stroke patients with active cancer between 2010 and 2020. Early neurological deterioration (END) was defined as an increase of ≥ 1 in the motor NIHSS score, or ≥ 2 in the total NIHSS score within 72 hours of admission. Unfavorable outcomes were defined as a score of ≥ 3 on the 3-month modified Rankin Scale. RESULTS In total, 116 ischemic stroke patients with active cancer were evaluated. In multivariable analysis, ICAS was positively associated with END (adjusted odds ratio [aOR] = 4.56, 95% confidence interval [CI]: 1.52-13.70), and this association showed a quantitative relationship according to the degree of stenosis of ICAS (stenosis group: aOR = 4.24, 95% CI: 1.31-13.72; occlusion group, aOR = 5.74, 95% CI: 1.05-31.30). ICAS was also closely related to unfavorable outcomes (aOR = 6.33, 95% CI: 1.15-34.79). In contrast, AF showed no significant association with END or unfavorable outcomes. Our data showed that patients with ICAS had larger and more severe initial stroke lesions, and poorer prognosis than those without. CONCLUSIONS ICAS, but not AF, was closely associated with poor prognosis in ischemic stroke patients with active cancer.
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Affiliation(s)
- Ki-Woong Nam
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyung-Min Kwon
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Yong-Seok Lee
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
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18
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Nam KW, Kwon HM, Lee YS, Kim JM, Ko SB. Effects of cerebral small vessel disease on the outcomes in cryptogenic stroke with active cancer. Sci Rep 2021; 11:17510. [PMID: 34471193 PMCID: PMC8410810 DOI: 10.1038/s41598-021-97154-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 08/20/2021] [Indexed: 11/09/2022] Open
Abstract
Cerebral small vessel diseases (cSVDs) affect the prognosis of various types of ischemic stroke. Therefore, we evaluated the association between cSVD and the prognosis of cryptogenic stroke patients with active cancer. We enrolled patients diagnosed with cryptogenic stroke and active cancer from 2010 to 2016. Early neurological deterioration (END) was defined as a ≥ 2-point increase in the total NIHSS score or a ≥ 1-point increase in the motor NIHSS score within the first 72 h. We defined an unfavorable outcome as the modified Rankin Scale (mRS) score ≥ 3 points. We analyzed cSVD separately for each subtype including white matter hyperintensity (WMH), silent brain infarct (SBI), and cerebral microbleed (CMB). A total of 179 cryptogenic stroke patients with active cancer were evaluated. In the multivariable analysis, SBI was significantly associated with END (adjusted odds ratio = 3.97, 95% confidence interval: 1.53–10.33). This close relationship between SBI and END increased proportionally with an increase in SBI burden. However, WMH and CMB showed no significant association with END. None of the cSVD subtypes showed a statistically significant relationship with the 3-month unfavorable outcome. SBI was the only parameter closely associated with END in cryptogenic stroke patients with active cancer.
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Affiliation(s)
- Ki-Woong Nam
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-Gu, Seoul, 07061, South Korea
| | - Hyung-Min Kwon
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea. .,Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-Gu, Seoul, 07061, South Korea.
| | - Yong-Seok Lee
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-Gu, Seoul, 07061, South Korea
| | - Jeong-Min Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-Gu, Seoul, 07061, South Korea. .,Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehakno, Jongno-Gu, Seoul, 03080, South Korea.
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-Gu, Seoul, 07061, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehakno, Jongno-Gu, Seoul, 03080, South Korea
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Yamaura G, Ito T, Miyaji Y, Ueda N, Nakae Y, Momoo T, Nakano T, Johmura Y, Higashiyama Y, Joki H, Doi H, Takeuchi H, Takahashi T, Koyano S, Yamaguchi S, Yokoyama M, Tanaka F. Therapeutic efficacy of heparin and direct factor Xa inhibitors in cancer-associated cryptogenic ischemic stroke with venous thromboembolism. Thromb Res 2021; 206:99-103. [PMID: 34454242 DOI: 10.1016/j.thromres.2021.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Anticoagulation therapy, especially using heparin or recently developed oral direct factor Xa inhibitors (DiXals), is recommended as first-line treatment for cancer-related venous thromboembolism (VTE). However, the preventive efficacy of these anticoagulants for cancer-associated ischemic stroke is still unknown. We retrospectively investigated the efficacy of subcutaneous unfractionated heparin (UFH) and DiXals for preventing the recurrence of cancer-associated cryptogenic ischemic stroke with VTE. METHODS We retrospectively studied consecutive patients with cancer-associated cryptogenic ischemic stroke and comorbid VTE who received subcutaneous UFH or oral DiXaIs at 9 hospitals. RESULT Fifty-three patients (24 treated with UFH and 29 treated with DiXaIs) were enrolled. Of these, 47 demonstrated systemic metastasis (cancer stage IV). During 30-day follow-up after initiation of anticoagulation therapy, recurrent ischemic stroke was observed in only 1 patient (4%) in the UFH group and in 9 patients (31%) in the DiXal group. The incidence of major bleeding complications was similar between the 2 groups (4% and 10%, respectively). The cumulative risk of ischemic stroke recurrence within 30 days was lower with UFH than with DiXals (competing risk analysis, p = 0.008). In the DiXal group, patients who experienced recurrence showed significantly higher D-dimer levels than those without recurrence. CONCLUSION In patients with cancer-associated cryptogenic ischemic stroke and comorbid VTE, UFH demonstrated a lower rate of recurrent ischemic stroke than DiXaIs, and there were no differences in bleeding risk between the 2 treatments. D-dimer levels at stroke onset increased the risk of recurrence in the DiXal group but not in the UFH group.
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Affiliation(s)
- Genpei Yamaura
- Department of Neurology, Fujisawa City Hospital, 2-6-1 Fujisawa, Fujisawa 251-8550, Japan
| | - Takeshi Ito
- Department of Neurology, Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawanishimachi, Kanagawa-ku, Yokohama 221-0855, Japan
| | - Yosuke Miyaji
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Naohisa Ueda
- Department of Neurology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Yoshiharu Nakae
- Department of Neurology, Saiseikai Yokohamashi Nanbu Hospital, 3-2-10 Konandai, Konan-ku, Yokohama 234-0054, Japan
| | - Takayuki Momoo
- Department of Neurology, Hiratsuka Kyosai Hospital, 9-11 Oiwake, Hiratsuka 254-8502, Japan
| | - Tatsu Nakano
- Department of Neurology and Stroke Medicine, Yokohama Sakae Kyosai Hospital, 132 Katsura-cho, Sakae-ku, Yokohama 247-8581, Japan
| | - Yuji Johmura
- Department of Neurology, Yokohama Minami Kyousai Hospital, 1-21-1 Mutsuurahigashi, Kanazawa-ku, Yokohama 236-0037, Japan
| | - Yuichi Higashiyama
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Hideto Joki
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Hiroshi Doi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Hideyuki Takeuchi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Tatsuya Takahashi
- Department of Neurology, National Hospital Organization Yokohama Medical Center, 3-60-2 Harajuku, Totsuka-ku, Yokohama 245-8575, Japan
| | - Shigeru Koyano
- Department of Neurology, Yokohama Minami Kyousai Hospital, 1-21-1 Mutsuurahigashi, Kanazawa-ku, Yokohama 236-0037, Japan
| | - Shigeki Yamaguchi
- Department of Neurology, Yokohama Municipal Citizen's Hospital, 1-1 Mitsuzawanishimachi, Kanagawa-ku, Yokohama 221-0855, Japan
| | - Mutsumi Yokoyama
- Department of Neurology, Fujisawa City Hospital, 2-6-1 Fujisawa, Fujisawa 251-8550, Japan
| | - Fumiaki Tanaka
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
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20
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Navi BB, Sherman CP, Genova R, Mathias R, Lansdale KN, LeMoss NM, Wolfe J, Skakodub A, Kamel H, Tagawa ST, Saxena A, Ocean AJ, Soff GA, DeSancho MT, Iadecola C, Elkind MSV, Peerschke E, Zhang C, DeAngelis LM. Mechanisms of Ischemic Stroke in Patients with Cancer: A Prospective Study. Ann Neurol 2021; 90:159-169. [PMID: 34029423 DOI: 10.1002/ana.26129] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The objective of this study was to examine the pathophysiology of ischemic stroke with cancer. METHODS We conducted a prospective cross-sectional study from 2016 to 2020 at 2 hospitals. We enrolled 3 groups of 50 adult participants each. The main group included patients with active solid tumor cancer and acute ischemic stroke. The control groups included patients with acute ischemic stroke only or active cancer only. The patients with stroke-only and patients with cancer-only were matched to the patients with cancer-plus-stroke by age, sex, and cancer type, if applicable. The outcomes were prespecified hematological biomarkers and transcranial Doppler microemboli detection. Hematological biomarkers included markers of coagulation (D-dimer and thrombin-antithrombin), platelet function (P-selectin), and endothelial integrity (thrombomodulin, soluble intercellular adhesion molecule-1 [sICAM-1], and soluble vascular cell adhesion molecule-1 [sVCAM-1]). Hematological biomarkers were compared between groups using the Kruskal-Wallis and Wilcoxon Rank-Sum tests. In multivariable linear regression models, we adjusted for race, number of stroke risk factors, smoking, stroke severity, and antithrombotic use. Transcranial Doppler microemboli presence was compared between groups using chi-square tests. RESULTS Levels of all study biomarkers were different between groups. In univariate between-group comparisons, patients with cancer-plus-stroke had higher levels of D-dimer, sICAM-1, sVCAM-1, and thrombomodulin than both control groups; higher levels of thrombin-antithrombin than patients with cancer-only; and higher levels of P-selectin than patients with stroke-only. Findings were similar in multivariable analyses. Transcranial Doppler microemboli were detected in 32% of patients with cancer-plus-stroke, 16% of patients with stroke-only, and 6% of patients with cancer-only (p = 0.005). INTERPRETATION Patients with cancer-related stroke have higher markers of coagulation, platelet, and endothelial dysfunction, and more circulating microemboli, than matched controls. ANN NEUROL 2021;90:159-169.
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Affiliation(s)
- Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York.,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Carla P Sherman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Richard Genova
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Ryna Mathias
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Kelsey N Lansdale
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Natalie M LeMoss
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Julia Wolfe
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anna Skakodub
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Scott T Tagawa
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Ashish Saxena
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Allyson J Ocean
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Gerald A Soff
- Division of Hematologic Malignancies, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria T DeSancho
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
| | - 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, New York
| | - Ellinor Peerschke
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
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21
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Pana TA, Mohamed MO, Mamas MA, Myint PK. Prognosis of Acute Ischaemic Stroke Patients with Cancer: A National Inpatient Sample Study. Cancers (Basel) 2021; 13:cancers13092193. [PMID: 34063601 PMCID: PMC8125286 DOI: 10.3390/cancers13092193] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/25/2021] [Accepted: 04/28/2021] [Indexed: 12/20/2022] Open
Abstract
Whilst cancer is a risk factor for acute ischaemic stroke (AIS), its impact on AIS prognosis between metastatic and non-metastatic (MC and NMC) disease is poorly understood. Furthermore, the receipt of intravenous thrombolysis (IVT) and endovascular thrombectomy (ET) and their outcomes is poorly researched. AIS admissions from the National Inpatient Sample (NIS) were included (October 2015-December 2017). Multivariable logistic regressions adjusting for a wide range of confounders analysed the relationship between NMC and MC and AIS in-hospital outcomes (mortality, prolonged hospitalisation >4 days and routine home discharge). Interaction terms with IVT and ET were also computed to explore their impact amongst cancer patients. A total of 221,249 records representative of 1,106,045 admissions were included. There were 38,855 (3.51%) AIS admissions with co-morbid cancer: NMC = 53.78% and MC = 46.22%. NMC was associated with 23% increased odds of in-hospital mortality (odds ratio (95% confidence interval) = 1.23 (1.07-1.42)), which was mainly driven by pancreatic and respiratory cancers. This association was entirely offset by both IVT and ET. MC was associated with two-fold increased odds of in-hospital mortality (2.16 (1.90-2.45)), which was mainly driven by respiratory, pancreatic and colorectal cancers. This association was only offset by ET. Both NMC and MC were significantly associated with prolonged hospitalisation and decreased odds of routine discharge. Cancer patients are at higher odds of acute adverse outcomes after AIS and warrant robust primary prevention. IVT and ET improve these outcomes and should thus be offered routinely unless otherwise contraindicated in this group of stroke patients.
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Affiliation(s)
- Tiberiu A. Pana
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent ST4 6QG, UK; (M.O.M.); (M.A.M.); (P.K.M.)
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Correspondence:
| | - Mohamed O. Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent ST4 6QG, UK; (M.O.M.); (M.A.M.); (P.K.M.)
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent ST4 6QG, UK; (M.O.M.); (M.A.M.); (P.K.M.)
| | - Phyo K. Myint
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent ST4 6QG, UK; (M.O.M.); (M.A.M.); (P.K.M.)
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
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22
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Yoo J, Kim YD, Park H, Kim BM, Bang OY, Kim HC, Han E, Kim DJ, Heo J, Kim M, Choi JK, Lee KY, Lee HS, Shin DH, Choi HY, Sohn SI, Hong JH, Lee JY, Baek JH, Kim GS, Seo WK, Chung JW, Kim SH, Song TJ, Han SW, Park JH, Kim J, Jung YH, Cho HJ, Ahn SH, Lee SI, Seo KD, Heo JH, Nam HS. Immediate and Long-Term Outcomes of Reperfusion Therapy in Patients With Cancer. Stroke 2021; 52:2026-2034. [PMID: 33910369 DOI: 10.1161/strokeaha.120.032380] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Joonsang Yoo
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Yongin Severance Hospital (J.Y., J.K.), Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
| | - Hyungjong Park
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea (H.P., S.-I.S., J.-H.H.)
| | - Byung Moon Kim
- Department of Radiology (B.M.K., D.J.K.), Yonsei University College of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (O.Y.B., W.-K.S., J.-W.C.)
| | - Hyeon Chang Kim
- Department of Preventive Medicine (H.C.K.), Yonsei University College of Medicine, Seoul, Korea
| | - Euna Han
- College of Pharmacy, Yonsei Institute for Pharmaceutical Research, Yonsei University, Incheon, South Korea (E.H.)
| | - Dong Joon Kim
- Department of Radiology (B.M.K., D.J.K.), Yonsei University College of Medicine, Seoul, Korea
| | - Joonnyung Heo
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
| | - Minyoung Kim
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyo Choi
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Severance Institute for Vascular and Metabolic Research (K.-Y.L., Y.H.J.), Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Department of Research Affairs (H.S.L.), Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hoon Shin
- Department of Neurology, Gachon University Gil Medical Center, Incheon, Korea (D.H.S.)
| | - Hye-Yeon Choi
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea (H.-Y.C.)
| | - Sung-Il Sohn
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea (H.P., S.-I.S., J.-H.H.)
| | - Jeong-Ho Hong
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea (H.P., S.-I.S., J.-H.H.)
| | - Jong Yun Lee
- Department of Neurology, National Medical Center, Seoul, Korea (J.Y.L., J.-H.B.)
| | - Jang-Hyun Baek
- Department of Neurology, National Medical Center, Seoul, Korea (J.Y.L., J.-H.B.).,Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (J.-H.B.)
| | - Gyu Sik Kim
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea (G.S.K., K.-D.S.)
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (O.Y.B., W.-K.S., J.-W.C.)
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (O.Y.B., W.-K.S., J.-W.C.)
| | - Seo Hyun Kim
- Department of Neurology, Yonsei University Wonju College of Medicine, Korea (S.H.K.)
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, College of Medicine, Ewha Woman's University, Korea (T.-J.S.)
| | - Sang Won Han
- Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea (S.W.H., J.H.P.)
| | - Joong Hyun Park
- Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea (S.W.H., J.H.P.)
| | - Jinkwon Kim
- Department of Neurology, Yongin Severance Hospital (J.Y., J.K.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam, Korea (J.K.)
| | - Yo Han Jung
- Department of Neurology, Gangnam Severance Hospital, Severance Institute for Vascular and Metabolic Research (K.-Y.L., Y.H.J.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Changwon Fatima Hospital, Korea (Y.H.J.)
| | - Han-Jin Cho
- Department of Neurology, Pusan National University School of Medicine, Busan, Korea (H.-J.C.)
| | - Seong Hwan Ahn
- Department of Neurology, Chosun University School of Medicine, Gwangju, Korea (S.H.A.)
| | - Sung Ik Lee
- Department of Neurology, Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea (S.I.L., K.-D.S.)
| | - Kwon-Duk Seo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea (G.S.K., K.-D.S.).,Department of Neurology, Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea (S.I.L., K.-D.S.)
| | | | - Hyo Suk Nam
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
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23
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Roth P, Pace A, Le Rhun E, Weller M, Ay C, Cohen-Jonathan Moyal E, Coomans M, Giusti R, Jordan K, Nishikawa R, Winkler F, Hong JT, Ruda R, Villà S, Taphoorn MJB, Wick W, Preusser M. Neurological and vascular complications of primary and secondary brain tumours: EANO-ESMO Clinical Practice Guidelines for prophylaxis, diagnosis, treatment and follow-up. Ann Oncol 2021; 32:171-182. [PMID: 33246022 DOI: 10.1016/j.annonc.2020.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 02/08/2023] Open
Affiliation(s)
- P Roth
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - A Pace
- Neuroncology Unit, IRCCS Regina Elena Cancer Institute, Rome, Italy
| | - E Le Rhun
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland; Université Lille, U-1192, Lille, France; Inserm, U-1192, Lille, France; Centre Hospitalier Universitaire CHU, Lille, General and Stereotaxic Neurosurgery Service, Lille, France; Oscar Lambret Center, Breast Cancer Department, Lille, France
| | - M Weller
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - C Ay
- Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Vienna, Austria
| | - E Cohen-Jonathan Moyal
- Radiation Oncology Department, Institut Claudius Regaud, Université Paul Sabatier, Toulouse, France; Institut Universitaire du Cancer de Toulouse IUCT Oncopole, Toulouse, France
| | - M Coomans
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - R Giusti
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Sant'Andrea, Rome, Italy
| | - K Jordan
- Department of Medicine V, Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - R Nishikawa
- Department of Neuro-Oncology/Neurosurgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - F Winkler
- Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany; Clinical Cooperation Unit Neurooncology, German Cancer Research Center (DKFZ), Heidelberg, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany
| | - J T Hong
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, Seoul, The Catholic University of Korea, Republic of Korea
| | - R Ruda
- Department of Neuro-Oncology, City of Health and Science and University of Turin, Turin, Italy
| | - S Villà
- Catalan Institute of Oncology, HU Germans Trias, Badalona, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - W Wick
- Department of Neurology and Neurooncology Program, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - M Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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24
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Navi BB, Kasner SE, Elkind MSV, Cushman M, Bang OY, DeAngelis LM. Cancer and Embolic Stroke of Undetermined Source. Stroke 2021; 52:1121-1130. [PMID: 33504187 DOI: 10.1161/strokeaha.120.032002] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
One-quarter to one-third of ischemic strokes have no established mechanism after standard diagnostic evaluation and are classified as embolic stroke of undetermined source (ESUS). Failure of randomized trials to demonstrate a benefit of direct oral anticoagulants over aspirin for the treatment of ESUS as a single homogeneous entity has led to renewed interest by stroke experts to divide ESUS into subgroups. Emerging data suggest that active cancer, which is present in 5% to 10% of patients with ESUS, is a distinct and important subgroup of ESUS with unique clinical characteristics, underlying pathophysiologies, and treatment and prognostic considerations. Furthermore, the prevalence of cancer-related ESUS is expected to increase as patients with cancer, even those with distant metastases, survive longer due to improvements in cancer treatments. In this topical review, we examine the epidemiological link between ESUS and cancer, the clinical features and potential mechanistic underpinnings of ESUS with cancer (with a focus on novel biomarkers and their relationship to recurrent stroke and other thromboembolic events), and the potential treatment strategies for cancer-related ESUS. We include a critical appraisal of existing data and ongoing or planned clinical trials of different antithrombotic approaches. As cancer-related ESUS is a dynamic disease with variable course, we recommend close collaboration between neurologists and oncologists to develop individualized management plans.
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Affiliation(s)
- Babak B Navi
- Clinical and Translational Neuroscience Unit, Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY (B.B.N.).,Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY (B.B.N., L.M.D.)
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (S.E.K.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY (M.S.V.E.)
| | - Mary Cushman
- Division of Hematology and Oncology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington (M.C.)
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.)
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY (B.B.N., L.M.D.)
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25
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Salazar-Camelo RA, Moreno-Vargas EA, Cardona AF, Bayona-Ortiz HF. Ischemic stroke: A paradoxical manifestation of cancer. Crit Rev Oncol Hematol 2020; 157:103181. [PMID: 33264715 DOI: 10.1016/j.critrevonc.2020.103181] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 10/01/2020] [Accepted: 11/11/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Approximately 5-10 % of the patients with cryptogenic stroke have an underlying malignancy. Stroke as a complication of cancer increases the morbidity and mortality among cancer patients, leading to increased disability and healthcare costs. OBJECTIVE To provide elements to guide physicians for when to suspect and evaluate for cancer in stroke patients. DEVELOPMENT We performed a narrative review, portrayed in a question-answer format, to report relevant aspects of cancer stroke patients in the clinical practice and provide a guide based on the state-of-the-art literature. Conventional stroke mechanisms are only found in a fraction of patients with cancer. Although cardiovascular risk factors play an important role in both cancer and stroke pathogenesis, the recognition of more specific cancer-associated risk factors raises clinical suspicion for occult malignancy. We also expose the main type location and histology of tumors that are most commonly associated with stroke as well as potential blood biomarkers and current treatment considerations in the scenario of cancer associated stroke. CONCLUSION Subjects with active cancer are a patient population at increased risk for developing an ischemic stroke. Cryptogenic stroke patients have a higher risk of cancer diagnosis in the following 6-12 months. We recommend a multidisciplinary approach considering the high probability of a hidden malignancy and running a comprehensive evaluation including neurologic imaging, serological biomarkers and tight follow up.
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Affiliation(s)
- Ruth A Salazar-Camelo
- Neurology Department, Hospital Universitario Fundación Santa Fe Colombia, Bogotá, Colombia; Universidad los Andes Colombia, School of Medicine, Bogotá, Colombia.
| | - Eder A Moreno-Vargas
- Neurology Department, Hospital Universitario Fundación Santa Fe Colombia, Bogotá, Colombia; Universidad los Andes Colombia, School of Medicine, Bogotá, Colombia.
| | - Andrés F Cardona
- Clinical and Traslational Oncology Group, Clínica del Country, Bogotá, Colombia; Foundation for Clinical and Applied Cancer Research - FICMAC, Bogotá, Colombia; Molecular Oncology and Biology Systems Reasearch Group (Fox-G), Universidad El Bosque, Bogotá, Colombia.
| | - Hernán F Bayona-Ortiz
- Neurology Department, Hospital Universitario Fundación Santa Fe Colombia, Bogotá, Colombia; Universidad los Andes Colombia, School of Medicine, Bogotá, Colombia; Universidad El Bosque Colombia, School of Medicine, Neurology program, Bogotá, Colombia.
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26
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Tsuchihashi Y, Shimizu T, Akiyama H, Hagiwara Y, Soga K, Takao N, Uchino K, Yanagisawa T, Yamauchi J, Sato T, Hasegawa Y, Yamano Y. The Risk Factors for Death within 6 Months After Ischemic Stroke in Patients with Cancer. J Stroke Cerebrovasc Dis 2020; 29:105365. [PMID: 33075707 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/07/2020] [Accepted: 09/24/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES While the intravenous recombinant tissue plasminogen activator (rt-PA) therapy for acute ischemic stroke patients with cancer is recommended when survival of ≥ 6 months is expected, the risk factors for death and stroke recurrence within 6 months after stroke are not well known. Thus, we aimed to identify markers for death and recurrence risks within six months from stroke onset in patients with cancer. MATERIALS AND METHODS In a retrospective cohort study, the subjects comprised acute ischemic stroke patients with cancer hospitalized at St. Marianna University hospital from 2008 through 2019. To evaluate the associations between the clinical factors within 24 h of the initial stroke and death or stroke recurrence events within 6 months from stroke onset, Logistic analysis and Cox proportional hazards regression analysis was used respectively. Next, the optimal cutoff point of markers for different mortality groups was determined using the receiver operating characteristic curve analysis and cumulative outcome rate of each group was compared using the Kaplan-Meier method. RESULTS Among 194 patients with cancer who developed acute stroke, 167 were ultimately selected for analysis. 47 subjects (28.14%) passed away within 6 months following stroke onset, and 20 subjects (11.98%) had stroke recurrence. High D-dimer levels, low fibrinogen levels, high Glasgow prognostic scores (GPS), and multiple vascular territory infarctions was independently associated with death, where higher death rate was significantly confirmed in the group with D-dimer levels of ≥3.95 mg/dl, fibrinogen levels <277.5 mg/dl and GPS scores of 2. Low fibrinogen level, lack of antithrombotic therapy, and the presence of metastasis were associated with stroke recurrence. CONCLUSIONS When patients with cancer suffer stroke, D-dimer levels, fibrinogen levels, GPS, and multiple vascular territory infarctions would be associated with the risk of death within 6 months. Low fibrinogen levels, lack of antithrombotic therapy, and the presence of metastasis correlated with high risk of stroke recurrence.
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Affiliation(s)
- Yoko Tsuchihashi
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa 216-8511, Japan.
| | - Takahiro Shimizu
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa 216-8511, Japan.
| | - Hisanao Akiyama
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa 216-8511, Japan.
| | - Yuta Hagiwara
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa 216-8511, Japan.
| | - Kaima Soga
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa 216-8511, Japan.
| | - Naoki Takao
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa 216-8511, Japan.
| | - Kenji Uchino
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa 216-8511, Japan.
| | - Toshiyuki Yanagisawa
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa 216-8511, Japan.
| | - Junji Yamauchi
- Department of Rare Diseases Research, Institute of Medical Science, St. Marianna University School of Medicine, Kanagawa, Japan.
| | - Tomoo Sato
- Department of Rare Diseases Research, Institute of Medical Science, St. Marianna University School of Medicine, Kanagawa, Japan.
| | - Yasuhiro Hasegawa
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa 216-8511, Japan; Division of Neurology, Department of Internal Medicine, SHIN-YURIGAOKA General Hospital, Kanagawa, Japan.
| | - Yoshihisa Yamano
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Kanagawa 216-8511, Japan; Department of Rare Diseases Research, Institute of Medical Science, St. Marianna University School of Medicine, Kanagawa, Japan.
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Pathophysiology, Mechanism, and Outcome of Ischemic Stroke in Cancer Patients. J Stroke Cerebrovasc Dis 2020; 29:105299. [PMID: 32951960 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105299] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES The purpose of this study is to assess the risk factors, biomarkers of stroke, mechanism, and outcomes of cerebral infarction among cancerous diseases. MATERIALS & METHODS 156 patients presented by acute ischemic stroke were divided into two groups: the first group included 78 ischemic stroke patients associated with different types of cancer and the second group (control group) included 78 ischemic stroke patients not associated with cancer. Both groups were compared regarding the risk factors, previous thrombotic activity, subtypes, biomarkers of stroke, and outcomes. RESULTS Cancer patients presented by acute ischemic stroke were accompanied by a significantly less incidence of diabetes mellitus, hypertension, dyslipidemia, and coronary heart disease, and atrial fibrillation than non-cancer patients (P < 0.001). While, levels of biomarkers of inflammation like erythrocyte sedimentation rate and C-reactive protein, and stroke biomarkers like fibrinogen, and D-dimer, all together were highly elevated in cancerous disease group of patients (P < 0.01). The prevalence of deep vein thrombosis, pulmonary embolism, and myocardial infarction was significantly higher in patients with cancer than in control patients without cancer (P = 0.008, P < 0.01 and P < 0.01 respectively). The most common stroke etiologies were atherosclerosis of large arteries and stroke of undetermined cause in a cancerous group of patients. Cancer patients were accompanied by significant higher mortality rate (P = 0.005), and more disability as determined by mRS (P < 0.005) CONCLUSIONS: Pathophysiology and mechanism of ischemic stroke in cancerous disease patients were due to different risk factors, biomarkers of stroke, and subtypes in comparison with non- cancerous cases.
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Prognostic role of the controlling nutritional status score in acute ischemic stroke among stroke subtypes. J Neurol Sci 2020; 416:116984. [DOI: 10.1016/j.jns.2020.116984] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 11/17/2022]
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Gon Y, Kabata D, Kawano T, Kanki H, Todo K, Sasaki T, Shintani A, Mochizuki H. Hematological Abnormalities and Malnutrition Mediate Pathway between Cancer and Outcomes in Ischemic Stroke Patients. J Stroke Cerebrovasc Dis 2020; 29:104943. [PMID: 32689614 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104943] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/16/2020] [Accepted: 05/05/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The present study aimed to examine whether variables including D-dimer, high-sensitivity C-reactive protein (hsCRP), hemoglobin, platelet count, and nutritional status mediate the pathway between cancer and ischemic stroke outcomes. METHODS We reviewed data from consecutive patients with ischemic stroke admitted to Osaka University Hospital between January 1, 2006, and December 31, 2016. Patients with ischemic stroke were grouped according to the presence of cancer. Nutritional status was assessed using Controlling Nutritional Status (CONUT) scores. Mediation analyses were utilized to address the study aims. RESULTS Among 1,570 patients with ischemic stroke, 185 (12%) had active cancer. Relative to patients with ischemic stroke in the non-cancer group, those in the cancer group exhibited higher National Institutes of Health Stroke Scale scores on admission, higher D-dimer and hsCRP levels, lower hemoglobin levels and platelet counts, higher CONUT scores, and poorer modified Rankin Scale scores at discharge. Mediation analysis revealed that D-dimer, hsCRP, hemoglobin, platelet count, and CONUT scores acted as mediators of poor prognosis in the cancer group. The association between the exposure and outcome variables was no longer significant in the models containing D-dimer and CONUT scores as mediator variables, suggesting that they were strong mediators. Regarding the association between the mediator and outcome variables, hemoglobin, platelet count, and CONUT exhibited non-linearity (p for non-linearity < 0.001). CONCLUSIONS D-dimer, hsCRP, hemoglobin, platelet count, and CONUT score act as mediators of poor prognosis in patients with ischemic stroke with comorbid cancer. Such abnormalities can help to predict ischemic stroke outcomes.
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Affiliation(s)
- Yasufumi Gon
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan; Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Tomohiro Kawano
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideaki Kanki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
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Yoo J, Choi JK, Kim YD, Nam HS, Park H, Lee HS, Heo JH. Outcome of Stroke Patients with Cancer and Nonbacterial Thrombotic Endocarditis. J Stroke 2020; 22:245-253. [PMID: 32635688 PMCID: PMC7341006 DOI: 10.5853/jos.2020.00619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/21/2020] [Indexed: 12/23/2022] Open
Abstract
Background and Purpose Nonbacterial thrombotic endocarditis (NBTE) is a cause of stroke in cancer. However, clinical characteristics and outcomes in stroke patients with cancer-associated NBTE are not well known. Methods We included consecutive patients with stroke and active cancer over a 9-year period who underwent echocardiography. We retrospectively compared clinical characteristics and presence of metastasis between patients with NBTE, those with cryptogenic etiologies, and those with determined etiologies. We also investigated mortality and stroke events during the 6-month follow-up. Results Among the 245 patients, 20 had NBTE, 96 had cryptogenic etiologies, and 129 had determined etiologies. Metastasis was seen in all 20 patients (100%) with NBTE, 69.8% in patients with cryptogenic etiology, and 48.8% in patients with or determined etiology. During the 6-month follow-up, 127 patients (51.8%) developed stroke and/or died (death in 110 [44.9%] and stroke events in 55 [22.4%]). Patients with NBTE showed significantly higher mortality (80%) and stroke occurrence (50%) than those with cryptogenic etiologies (mortality 54.2%, stroke 25.0%, log-rank P=0.006) and determined etiologies (mortality 32.6%, stroke 16.3%, log-rank P<0.001). In a multivariate Cox proportional hazard analysis, the presence of NBTE was independently associated with composite outcomes of mortality and stroke events (hazard ratio, 1.941; 95% confidence interval, 1.052 to 3.690). Conclusions NBTE should be suspected as a potential cause of stroke in patients with metastatic cancer. Patients with NBTE have a high risk of recurrent stroke and mortality. Future studies are necessary to determine strategies to reduce stroke recurrence in patients with NBTE.
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Affiliation(s)
- Joonsang Yoo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea.,Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyo Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Hyungjong Park
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
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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.
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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,
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Martinez-Majander N, Ntaios G, Liu YY, Ylikotila P, Joensuu H, Saarinen J, Perera KS, Marti-Fabregas J, Chamorro A, Rudilosso S, Prats-Sanchez L, Berkowitz SD, Mundl H, Themeles E, Tiainen M, Demchuk A, Kasner SE, Hart RG, Tatlisumak T. Rivaroxaban versus aspirin for secondary prevention of ischaemic stroke in patients with cancer: a subgroup analysis of the NAVIGATE ESUS randomized trial. Eur J Neurol 2020; 27:841-848. [PMID: 32056346 DOI: 10.1111/ene.14172] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 02/08/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Cancer is a frequent finding in ischaemic stroke patients. The frequency of cancer amongst participants in the NAVIGATE ESUS randomized trial and the distribution of outcome events during treatment with aspirin and rivaroxaban were investigated. METHODS Trial participation required a recent embolic stroke of undetermined source. Patients' history of cancer was recorded at the time of study entry. During a mean follow-up of 11 months, the effects of aspirin and rivaroxaban treatment on recurrent ischaemic stroke, major bleeding and all-cause mortality were compared between patients with cancer and patients without cancer. RESULTS Amongst 7213 randomized patients, 543 (7.5%) had cancer. Of all patients, 3609 were randomized to rivaroxaban [254 (7.0%) with cancer] and 3604 patients to aspirin [289 (8.0%) with cancer]. The annual rate of recurrent ischaemic stroke was 4.5% in non-cancer patients in the rivaroxaban arm and 4.6% in the aspirin arm [hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.78-1.24]. In cancer patients, the rate of recurrent ischaemic stroke was 7.7% in the rivaroxaban arm and 5.4% in the aspirin arm (HR 1.43, 95% CI 0.71-2.87). Amongst cancer patients, the annual rate of major bleeds was non-significantly higher for rivaroxaban than aspirin (2.9% vs. 1.1%; HR 2.57, 95% CI 0.67-9.96; P for interaction 0.95). All-cause mortality was similar in both groups. CONCLUSIONS Our exploratory analyses show that patients with embolic stroke of undetermined source and a history of cancer had similar rates of recurrent ischaemic strokes and all-cause mortality during aspirin and rivaroxaban treatments and that aspirin appeared safer than rivaroxaban in cancer patients regarding major bleeds. www.clinicaltrials.gov (NCT02313909).
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Affiliation(s)
- N Martinez-Majander
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - G Ntaios
- Department of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Y Y Liu
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - P Ylikotila
- Division of Clinical Neurosciences, Turku University Hospital, Turku, Finland
| | - H Joensuu
- Department of Oncology, Helsinki University Hospital, Helsinki, Finland
| | - J Saarinen
- Department of Neurology, Vaasa Central Hospital, Vaasa, Finland
| | - K S Perera
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - J Marti-Fabregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain
| | - A Chamorro
- Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, Spain
| | - S Rudilosso
- Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, Spain
| | - L Prats-Sanchez
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute, IIB-Sant Pau, Barcelona, Spain
| | | | - H Mundl
- Bayer Pharma AG, Wuppertal, Germany
| | - E Themeles
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - M Tiainen
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - A Demchuk
- Calgary Stroke Program, Departments of Clinical Neuroscience and Radiology and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - S E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - R G Hart
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - T Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Cheng X, Qin Q, Lu L, Chen C, Wei Y, Wang D, Li H, Li G, Liang H, Li S, Cheng D, Liang Z. The independent risks and specific biomarker of breast cancer-related ischemic stroke. Int J Neurosci 2020; 131:135-143. [PMID: 32083954 DOI: 10.1080/00207454.2020.1733562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM This retrospective study was designed to investigate the independent risks and specific biomarker for breast cancer-related ischemic stroke (BCRS). METHODS Clinical features and laboratory findings were compared between BCRS group and breast cancer group without stroke, and further multivariate analyses were performed to predict independent risks factors for BCRS patients. A receiver operator characteristic (ROC) curve analysis was configured to estimate the diagnostic efficacy of each independent risk and the product of these risks and to obtain the optimal cut-off value of diagnosis, which was termed the BCRS Index. RESULTS BCRS patients had elevated plasma D-dimer and CA153 levels and platelet-to-lymphocyte ratio (PLR), as well as more patients received endocrine therapy (all p < 0.05). Moreover, multivariate analysis revealed that D-dimer levels (odds ratio [OR]: 1.002; 95% confidence interval [CI]: 1.001-1.003; p = 0.000), CA153 levels (OR: 1.005; 95% CI: 1.001-1.008; p = 0.007), PLR (OR: 1.010; 95% CI: 1.004-1.015; p = 0.001), and endocrine therapy (OR: 1.268; 95% CI: 1.087-1.479; p = 0.003) were identified as independent risks of BCRS. Furthermore, ROC analysis displayed that the product of risks had the best diagnostic efficacy, of which the area under the curve was 0.846 ± 0.28. The optimum cut-off point was 2.37 × 106/mL, which was termed the BCRS Index with higher diagnostic accuracy and validity. CONCLUSIONS Endocrine therapy, as well as elevated plasma D-dimer and CA153 levels and PLR values may be independent risks for BCRS. Furthermore, BCRS Index should be served as a novel specific biomarker for BCRS, which is useful to distinguish BCRS for clinicians.
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Affiliation(s)
- Xuemin Cheng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Qixiong Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Lizhi Lu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Chunyong Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Yunfei Wei
- Department of Neurology, The Second Affliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Dacheng Wang
- Department of Neurology, The Ninth Affiliated Hospital of Guangxi Medical University, Beihai, Guangxi, China
| | - Haihua Li
- Department of Neurology, Fusui County People's Hospital, Chongzuo, Guangxi, China
| | - Guohui Li
- Department of Neurology, Wuzhou Red Cross Hospital, Wuzhou, Guangxi, China
| | - Hongbin Liang
- Department of Neurology, Cenxi People's Hospital, Cenxi, Guangxi, China
| | - Shengyu Li
- Department of Neurology, Wuming County People's Hospital, Nanning, Guangxi, China
| | - Daobin Cheng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University & Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention & Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, Guangxi, China
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Yuan Z, Cao D, Yu M, Zhou H, Zhang Y, Yang J, Shen K. Importance of Standard Treatment in Prognosis of Patients with Ovarian Cancer and Associated Cerebral Infarction. Clin Interv Aging 2020; 15:151-157. [PMID: 32103916 PMCID: PMC7014957 DOI: 10.2147/cia.s229236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/27/2019] [Indexed: 11/23/2022] Open
Abstract
Objective Data on the treatment of patients with ovarian cancer (OC) and associated cerebral infarction (CI) are extremely limited. The objectives were to investigate the risk factors for prognosis in patients with OC and associated CI. Methods We retrospectively reviewed the electronic medical records of patients with OC from January 2013 to November 2018 in Peking Union Medical Hospital. Results In total, 2632 inpatients were diagnosed with malignant ovarian cancer in our institution, and 30 patients (1.1%) were diagnosed with OC-associated CI. The median age was 60 years (range, 37–83). The standard treatment, according to National Comprehensive Cancer Network (NCCN) guidelines, was administered to 19 patients. The median follow-up time was 19.5 months (range, 1–59 months). In total, 17 patients experienced tumor progression, and 16 of them died. In univariate analysis, overall survival was significantly associated with the D-dimer level (P=0.017), FIGO stage (P=0.014), complete cytoreduction (P<0.000) and standard treatment (P<0.000). In multivariate analysis, the standard treatment remained an independent protective factor for death (hazard ratio=0.061, 95% confidence interval=0.007–0.537, P=0.012). Conclusion Although the prognosis of patients with OC and associated CI was poor, those who underwent the standard treatment still benefited.
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Affiliation(s)
- Zhen Yuan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Mei Yu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Huimei Zhou
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Ying Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jiaxin Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Keng Shen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Hasegawa Y, Setoguchi T, Sakaida T, Iuchi T. Utility of a scoring system for differentiating cancer-associated stroke from cryptogenic stroke in patients with cancer. Neurol Sci 2020; 41:1245-1250. [PMID: 31912335 DOI: 10.1007/s10072-019-04231-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 12/28/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The commonest type of ischemic cerebral stroke in patients with cancer is cryptogenic stroke (CRS), the majority of which are considered cancer-associated strokes (CAS) caused by multiple microemboli associated with hypercoagulation, known as Trousseau syndrome. However, detection of microemboli and diagnosing CAS is difficult. We have therefore developed a scoring system for diagnosing CAS. METHODS We retrospectively examined data of patients with cancer and stroke between 2006 and 2017. We identified risk factors for CRS, assigned them one or two points, and calculated total scores (Trousseau score) for each patient. We used overall survival after stroke (OSs) to validate the utility of the system. RESULTS In 181 consecutive strokes, CRS was the commonest type (43.6%) and had a short OSs (median 56 days). We identified the following five risks for CRS: high D-dimer concentration (≥ 10.0 μg/mL) and lesions in multiple territories (two points each); and active cancer, low platelet count (150,000/μL>) and female sex (one point each). Trousseau score ≥ 3 indicated CAS (50.3%), which had a median OSs of 50 days. Only CAS (hazard ratio 3.44 [2.34-5.10], P < 0.0001) and poor performance status (3 or 4) (2.27 [1.50-3.39], P = 0.0002) were risk factors for OSs; CRS was not. OSs of patients with non-CAS/CRS was significantly longer than that of those with CAS/CRS (404.5 days vs. 47 days, P = 0.0114), whereas OSs of CAS/non-CRS was much shorter than that of non-CAS/non-CRS (53 days vs. 547 days, P < 0.0001). CONCLUSION Trousseau scores simply and clearly identify CAS.
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Affiliation(s)
- Yuzo Hasegawa
- Division of Neurological Surgery, Chiba Cancer Center, 666-2 Nitonacho, Chuo-ku, Chiba-shi, Chiba, 260-8717, Japan.
| | - Taiki Setoguchi
- Division of Neurological Surgery, Chiba Cancer Center, 666-2 Nitonacho, Chuo-ku, Chiba-shi, Chiba, 260-8717, Japan
| | - Tsukasa Sakaida
- Division of Neurological Surgery, Chiba Cancer Center, 666-2 Nitonacho, Chuo-ku, Chiba-shi, Chiba, 260-8717, Japan
| | - Toshihiko Iuchi
- Division of Neurological Surgery, Chiba Cancer Center, 666-2 Nitonacho, Chuo-ku, Chiba-shi, Chiba, 260-8717, Japan
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Ha J, Lee MJ, Kim SJ, Park BY, Park H, Cho S, Chung JW, Seo WK, Kim GM, Bang OY, Chung CS. Prevalence and Impact of Venous and Arterial Thromboembolism in Patients With Embolic Stroke of Undetermined Source With or Without Active Cancer. J Am Heart Assoc 2019; 8:e013215. [PMID: 31640456 PMCID: PMC6898837 DOI: 10.1161/jaha.119.013215] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background An increased risk of acute ischemic stroke is recognized among patients with cancer. However, the mechanism behind cancer‐related stroke is unclear. In this study, we determined the presence of associated venous thromboembolism and arterial thromboembolism and their clinical impact on patients with cancer‐related stroke. Methods and Results Patients with embolic stroke of undetermined source with or without cancer were evaluated for venous thromboembolism (deep vein thrombosis [DVT] and/or pulmonary embolism) and arterial thromboembolism by using Doppler sonography to determine the presence of lower‐extremity DVT and the microembolic signal of the symptomatic cerebral circulation, respectively. Infarct volume was determined by diffusion‐weighted magnetic resonance imaging. The multivariable linear regression and Cox proportional hazard analysis were used to investigate the effect of DVT and microembolic signal on infarct volume and 1‐year survival, respectively. Of 142 screened patients, 118 were included (37 with, 81 without cancer). Those with cancer had a higher prevalence of DVT or microembolic signal than did the noncancer group (62.2% versus 19.8%; P<0.001). Among patients with cancer‐related stroke, DVT was associated with a greater infarct volume in magnetic resonance imaging (beta, 13.14; 95% CI, 1.62–24.66; P=0.028). Presence of DVT (hazard ratio, 16.79; 95% CI, 2.05–137.75; P=0.009) and microembolic signal (hazard ratio, 8.16; 95% CI, 1.36–48.85; P=0.022) were independent predictors of poor 1‐year survival. Conclusions Patients with cancer‐associated embolic stroke of undetermined source have an elevated risk of associated venous thromboembolism and arterial thromboembolism, both of which have a significant negative impact on 1‐year survival. The results of this study may enhance our understanding of cancer‐associated stroke and improve risk stratification of patients with this disease. Clinical Trial Registration URL: https://www.clinicaltrials.gov/.Unique identifier: NCT02212496
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Affiliation(s)
- Jongmok Ha
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Mi Ji Lee
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Suk Jae Kim
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Bo-Yong Park
- Department of Electronic Electrical and Computer Engineering Sungkyunkwan University Suwon Republic of Korea.,Center for Neuroscience Imaging Research Institute for Basic Science (IBS) Suwon Republic of Korea
| | - Hyunjin Park
- Center for Neuroscience Imaging Research Institute for Basic Science (IBS) Suwon Republic of Korea.,School of Electronic and Electrical Engineering Suwon Republic of Korea
| | - Soohyun Cho
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Jong-Won Chung
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Woo-Keun Seo
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Gyeong-Moon Kim
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Oh Young Bang
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Chin-Sang Chung
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
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Wang F, Hu XY, Cui ZM, Fang XM, Dai Z, Wang T, Guo DL. Clinical and Imaging Characteristics of Malignant Tumor Concurrent with Stroke. Cancer Biother Radiopharm 2019; 34:504-510. [PMID: 31295003 DOI: 10.1089/cbr.2019.2853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objectives: The present study aimed to retrospectively compare the clinical and imaging characteristics and laboratory data of patients with malignant tumor concurrent with acute ischemic stroke (IS) and patients with cerebral infarction only, and to analyze the potential related risk factors. Method: A total of 126 patients with acute cerebral infarction concurrent with malignant tumor were collected and assigned to the malignant tumor group. In addition, 120 patients hospitalized for routine acute IS during the same period were randomly selected as the control group. Demographic data and common risk factors of cerebrovascular disease, laboratory data, and imaging characteristics in these two groups were compared. Results: In the malignant tumor group, the age of onset was relatively low, and the National Institutes of Health Stroke Scale score, 90 d recurrence rate, and fatality rate were higher than for those in the control group (p < 0.05). However, most patients had no traditional risk factors of stroke. Biochemical results revealed that the peripheral hemoglobin of patients with malignant tumor and cerebral infarction was lower than for those in the control group (p < 0.05). Furthermore, the levels of D-dimer, fibrinogen, tumor markers CA125, CA199, and carcinoembryonic antigen were significantly elevated, and the difference was statistically significant (p < 0.05). Magnetic resonance imaging results revealed that multiple intracranial infarcts were more common in patients in the malignant tumor group, and the difference was statistically significant compared with patients with cerebral infarction only (p < 0.05). Conclusion: Patients with cancer and IS had fewer traditional stroke risk factors but more anemia as well as higher D-dimer level, tumor marker rate, short-term mortality, and stroke recurrence rate. Furthermore, lower age of onset and other characteristics, including multiple intracranial infarcts, can be regarded as important characteristics of such patients.
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Affiliation(s)
- Feng Wang
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Xiao-Yun Hu
- Department of Radiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Zhi-Ming Cui
- Department of Radiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Xiang-Ming Fang
- Department of Radiology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Zheng Dai
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Tao Wang
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Dao-Liu Guo
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
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Abstract
Patients with cancer-associated ischemic stroke pose similar clinical manifestations and image characteristics, mainly embolic infarction, as patients with atrial fibrillation do. D-dimer, a degraded product of fibrin polymer, is a useful indicator of hypercoagulability, which frequently increases in cancer-associated stroke, but not in stroke resulted from atrial fibrillation. The level of serum D-dimer is associated with mortality, prognosis, and recurrence of systemic thromboembolism in these patients. Theoretically, drugs block coagulation cascade, such as heparin and low-molecular-weight-heparin (LMWH), oral direct anticoagulants, could attenuate the status of hypercoagulation and decrease the amount of D-dimer. These drugs may be helpful to prevent thromboembolic events in patients with cancer-associated hypercoagulability. Vitamin K antagonist, warfarin, decreases the production of coagulation factors, but not interrupts coagulation cascade may not be helpful to decrease hypercoagulability, but increase the risk of bleeding. However, the treatment of cancer-associated embolic stroke is still controversial. This article reviews relevant clinical studies and proposes the applicability of direct oral anticoagulants from the pathophysiological mechanism.
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Affiliation(s)
- Jin-Yi Hsu
- Department of Neurology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - An-Bang Liu
- Department of Neurology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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Wei YC, Chen KF, Wu CL, Lee TW, Liu CH, Shyu YC, Lin CP. Stroke Rate Increases Around the Time of Cancer Diagnosis. Front Neurol 2019; 10:579. [PMID: 31231302 PMCID: PMC6566310 DOI: 10.3389/fneur.2019.00579] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/16/2019] [Indexed: 12/15/2022] Open
Abstract
Objective: To test whether strokes increase around the time of cancer diagnosis, we comprehensively examined the correlations of cancer and stroke by employing a population-based cohort study design. Methods: One million people insured under the Taiwan's National Health Insurance program in 2005 were randomly sampled to create the study's dataset. According to the presence of cancer and/or stroke, patients were separated into cancer and stroke, cancer-only, and stroke-only groups. Diagnoses of cancer, stroke, and comorbidities were defined according to ICD9-CM codes. Cancer and non-cancer populations were matched by age at cancer diagnosis, gender, and stroke risk factors, and each patient with cancer was matched with two non-cancer controls nested in the same year of cancer diagnosis. The hazards of stroke and cumulative incidences within a year after cancer diagnosis were evaluated using Fine and Gray's subdistributional hazard model. Results: The temporal distribution of first-ever stroke in patients with both cancer and stroke was a sharpened bell shape that peaked between 0.5 years before and after cancer diagnosis. Frequencies of stroke were further adjusted by number of cancer survivors. The monthly event rate of stroke remained nested around the time of cancer diagnosis in all strokes. Brain malignancies, lung cancer, gastric cancer, prostate cancer, and leukemia patients obtained higher ratio of stroke, while breast cancer and thyroid cancer patients had low percentage of combining stroke. When compared to non-cancer matched control, the hazard of stroke within one year after cancer diagnosis was increased by cancer at a subdistributional hazard ratio of 1.72 (95% confident interval 1.48 to 2.01; p < 0.0001). Conclusions: Cancer increased the risk of stroke and stroke events were nested around the time of cancer diagnosis, occurring 0.5 years prior to cancer on average regardless of stroke type.
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Affiliation(s)
- Yi-Chia Wei
- Department of Neurology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Keelung, Taiwan
- Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Kuan-Fu Chen
- Clinical Informatics and Medical Statistics Research Center, Chung Gung University, Taoyuan, Taiwan
- Department of Emergency, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chia-Lun Wu
- Department of Neurology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Keelung, Taiwan
| | - Tay-Wey Lee
- Biostatistical Consultation Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chi-Hung Liu
- Department of Neurology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Chiau Shyu
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ching-Po Lin
- Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan
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Neilson LE, Rogers LR, Sundararajan S. Evaluation and Treatment of a Patient With Recurrent Stroke in the Setting of Active Malignancy. Stroke 2019; 50:e9-e11. [PMID: 30580735 DOI: 10.1161/strokeaha.118.022088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Lee E Neilson
- From the Neurological Institute, University Hospitals Cleveland Medical Center, OH
| | - Lisa R Rogers
- From the Neurological Institute, University Hospitals Cleveland Medical Center, OH
| | - Sophia Sundararajan
- From the Neurological Institute, University Hospitals Cleveland Medical Center, OH
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Cacho-Díaz B, Spínola-Maroño H, Mendoza-Olivas LG. Clinical presentation, risk factors and outcome of central nervous system metastasis vs stroke in cancer patients. Curr Probl Cancer 2018; 43:324-330. [PMID: 30482399 DOI: 10.1016/j.currproblcancer.2018.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 09/24/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE Cancer and stroke are the second and third causes of death worldwide; brain metastases (BM) occur in one third of patients with cancer, any neurologic deficit in these population always prompts the clinician to discard metastases for their presence carries a bad outcome. Both might share clinical presentation and differences in their outcome are not entirely known. The aim was to compare risk factors, clinical presentation, and outcome of cancer patients with BM vs stroke. METHODS A descriptive study with prospectively acquired data from a cancer referral center included patients seen at the neuro-oncologic unit from March 2011 to February 2018 with confirmed cancer who had BM or stroke. RESULTS Six hundred and thirteen BM patients were compared with 268 with stroke and cancer. Demographic factors, cancer type, risk factors, clinical presentation, and outcome are presented. Median overall survival in months for those with any stroke was 15 (95%confidence interval [CI] 8.6-21.4)-5 (95%CI 0.12.4) for hemorrhagic stroke and 22 (95%CI 13.4-30.6) in the ischemic group-and for those with BM 12 (95%CI 10.4-13.6). Hemorrhagic stroke commonly found in stroke patients as well as focal motor weakness, aphasia, and altered mental status. BM was more common in breast and lung cancer with headache, visual complaint, and/or vertigo. CONCLUSION Survival in cancer patients with BM is not that different than those with stroke, but clinical presentation and risk factors were found different.
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Affiliation(s)
- Bernardo Cacho-Díaz
- Neuro-oncology Unit, Research Unit, Instituto Nacional de Cancerología, Mexico City, Mexico.
| | - Héctor Spínola-Maroño
- Neuro-oncology Unit, Research Unit, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Laura G Mendoza-Olivas
- Neuro-oncology Unit, Research Unit, Instituto Nacional de Cancerología, Mexico City, Mexico
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Murthy SB, Cushman M, Bobrow D, Kamel H, Merkler AE, Elkind MSV, DeAngelis LM, Navi BB. Ability of the Khorana score to predict recurrent thromboembolism in cancer patients with ischemic stroke. J Clin Neurosci 2018; 57:111-115. [PMID: 30145085 PMCID: PMC6191324 DOI: 10.1016/j.jocn.2018.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 07/20/2018] [Accepted: 08/12/2018] [Indexed: 12/12/2022]
Abstract
Cancer patients with acute ischemic stroke (AIS) are high-risk for recurrent thromboembolic events (RTE). Currently, no risk stratification model exists to predict RTE in this population. We tested the hypothesis that the Khorana score, a validated risk model for predicting venous thromboembolism in cancer patients, can effectively classify RTE risk in cancer patients with AIS. We retrospectively identified adults with active solid or hematological cancer diagnosed with AIS at a tertiary-care cancer center from 2005 to 2010. The Khorana score at the time of index stroke was calculated. The primary outcome was arterial or venous RTE. Cox regression was used to evaluate the association of the Khorana score and its individual components with RTE. Harrell's c-statistic was used to calculate the score's discriminatory ability. Among 263 AIS patients, median survival was 84 days (IQR 24-149 days) and 90 (34%) had RTE. The median Khorana score was 2 (IQR 1-2, range 0-5). Cumulative rate of RTE was 28% among patients who scored 0, 36% with scores of 1-2, and 32% with scores of 3-6. The overall Khorana score was marginally associated with RTE (HR, 1.14; 95% CI, 1.02-1.28). Of its individual components, only leukocytosis was associated with RTE (HR adjusted for other components, 1.45; 95% CI 1.11-1.90). The score's c-statistic for predicting RTE was 0.57. In this study, the Khorana score had poor discriminatory ability for predicting RTE in cancer patients with AIS. Future research is needed to identify better methods for predicting RTE in this high-risk population.
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Affiliation(s)
- Santosh B Murthy
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA; Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Mary Cushman
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT, USA
| | - Dylan Bobrow
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA; Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Alexander E Merkler
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA; Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Lisa M DeAngelis
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA; Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA; Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Babak B Navi
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA; Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA; Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Ito S, Kikuchi K, Ueda A, Nagao R, Maeda T, Murate K, Shima S, Mizutani Y, Niimi Y, Mutoh T. Changes in Serial D-Dimer Levels Predict the Prognoses of Trousseau's Syndrome Patients. Front Neurol 2018; 9:528. [PMID: 30018592 PMCID: PMC6037767 DOI: 10.3389/fneur.2018.00528] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 06/13/2018] [Indexed: 12/21/2022] Open
Abstract
Background: The development of acute multiple embolic infarctions (AMEI) resulting from cancer is known as Trousseau's syndrome (TS). At present, however, there is no good marker for predicting the prognosis of TS patients. In the present study, we evaluated the use of serial D-dimer levels as a prognostic marker for TS. Methods: This retrospective cohort study included 1,409 consecutive acute ischemic stroke patients. We selected a group of patients with TS showing AMEI (n = 38; TS group) and a group of patients with atrial fibrillation (Af) and AMEI (n = 35; Af group) as controls. Serial D-dimer levels were measured between days 7 and 28 after stroke (sub-acute phase) in 21 patients of the TS group and 24 patients of the Af group. Results: D-dimer levels at onset (acute phase) were significantly higher in the TS group (8.45 ± 1.79 μg/mL, n = 38) compared with the Af group (1.14 ± 0.14 μg/mL, n = 35) (p < 0.0001). In patients for whom serial D-dimer measurements were made, D-dimer levels measured at the sub-acute phase decreased to 0.48 ± 0.12 μg/mL (n = 24) in the Af group, but remained elevated in the TS group during the sub-acute phase (11.20 ± 2.77 μg/mL, n = 21) (p < 0.0001). In all TS patients in whom serial D-dimer measurements were made, D-dimer levels in 17 patients who died within 500 days (13.31 ± 3.23 μg/mL) were significantly higher than those of the four surviving patients (2.23 ± 0.38 μg/mL) (cut-off D-dimer level = 3.0 μg/mL) during this period. Moreover, serial D-dimer levels of 10 patients who died within 90 days (17.78 ± 4.60 μg/mL) were significantly higher than those of the 11 patients who survived up to 90 days (5.21 ± 2.12 μg/mL) (p < 0.05). Conclusions: Serial D-dimer levels may be a good biomarker for TS as well as a useful predictor of the prognosis of TS patients.
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Affiliation(s)
- Shinji Ito
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Koichi Kikuchi
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Akihiro Ueda
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Ryunosuke Nagao
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Toshiki Maeda
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Kenichiro Murate
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Sayuri Shima
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Yasuaki Mizutani
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Yoshiki Niimi
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
| | - Tatsuro Mutoh
- Department of Neurology, Fujita Health University School of Medicine, Aichi, Japan
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Naito H, Nezu T, Hosomi N, Aoki S, Ueno H, Ochi K, Maruyama H. Antithrombotic Therapy Strategy for Cancer-Associated Ischemic Stroke: A Case Series of 26 Patients. J Stroke Cerebrovasc Dis 2018; 27:e206-e211. [PMID: 29779882 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/17/2018] [Accepted: 04/19/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The risk of complications from thromboembolism is increased for patients with malignancy. Cancer-associated stroke is also a serious issue with regard to the management of patients with cancer because stroke incidence often causes disabilities that affect daily life and cancer treatment strategy. METHODS Between March 2011 and September 2017, 328 patients with acute ischemic stroke were registered to our hospital. RESULTS Of these patients, 26 (7.9%) had a cancer-associated stroke diagnosis, namely, Trousseau syndrome. After ischemic stroke onset, malignancy treatment was changed to palliative treatment for 11 patients. Eighteen patients died 1 year after ischemic stroke onset, and 15 of these patients underwent cancer treatment according to the best supportive care policy. Of those who died, 8 underwent anticoagulation therapy. We described the clinical courses of 3 cases among 26 cases with Trousseau syndrome. Two cases took direct oral anticoagulants (DOACs) due to cancer-associated venous thromboembolism before stroke onset, and there has been no stroke recurrence with subcutaneous unfractionated heparin. In the third case, when cancer activity was suppressed, we changed DOACs from subcutaneous unfractionated heparin and continued DOACs without thromboembolic events. CONCLUSIONS There is insufficient evidence regarding cases for which DOACs would be suitable for the prevention of thromboembolism and regarding its long-term efficacy and safety in patients with cancer. As it stands, heparin treatment, which has multifaceted antithrombotic actions, may be suitable for cancer-associated stroke prevention.
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Affiliation(s)
- Hiroyuki Naito
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Tomohisa Nezu
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan.
| | - Naohisa Hosomi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Shiro Aoki
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Hiroki Ueno
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Kazuhide Ochi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
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Yeşilot N, Ekizoğlu E, Çoban O. Clinical Features of Cancer Associated Ischemic Stroke. ACTA ACUST UNITED AC 2018; 55:113-117. [PMID: 30057450 DOI: 10.29399/npa.22999] [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] [Received: 11/16/2017] [Accepted: 12/10/2017] [Indexed: 01/02/2023]
Abstract
Introduction Cerebrovascular disease is the second most common cause of central nervous system involvement in cancer patients after metastases. Procoagulant substances secreted by tumour cells, cancer therapy, and embolus from tumour have been implicated in ischemic stroke (IS) in cancer patients. Methods Four thousand twenty patients with IS were prospectively recorded to the Istanbul Medical School Stroke Registry from August 1997 to May 2016. Ninety-two patients with IS and cancer and 3928 IS patients without cancer constituted the two groups. Results Hypertension, hyperlipidemia, and congestive heart failure were less commonly encountered in cancer stroke patients. Lacunar and posterior circulation syndromes were less common and total anterior circulation syndrome was more common in cancer patients (p<0.001). Multiple territory infarcts were more frequently seen in patients having overt or non-overt disseminated intravascular coagulopathy (DIC) compared to those without DIC. Median survival was significantly shorter in patients with cancer-related stroke. Conclusion Cancer associated stroke without other underlying etiology is a specific group of stroke patients presenting with multiple territorial infarcts, overt or non-overt disseminated intravascular coagulopathy, and poor prognosis.
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Affiliation(s)
- Nilüfer Yeşilot
- Department of Neurology, Istanbul Medical Faculty of Istanbul University, Istanbul, Turkey
| | - Esme Ekizoğlu
- Department of Neurology, Istanbul Medical Faculty of Istanbul University, Istanbul, Turkey
| | - Oğuzhan Çoban
- Department of Neurology, Istanbul Medical Faculty of Istanbul University, Istanbul, Turkey
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Navi BB, Iadecola C. Ischemic stroke in cancer patients: A review of an underappreciated pathology. Ann Neurol 2018; 83:873-883. [PMID: 29633334 PMCID: PMC6021225 DOI: 10.1002/ana.25227] [Citation(s) in RCA: 159] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 04/02/2018] [Accepted: 04/02/2018] [Indexed: 02/06/2023]
Abstract
Currently 1 in 10 patients with ischemic stroke have comorbid cancer, and this frequency is expected to increase with continued advances in cancer therapeutics prolonging median survival. Well known for its association with venous thrombosis, cancer has recently emerged as a significant risk factor for arterial thromboembolism, including stroke; however, the underlying mechanisms are uncertain. In addition, the optimal strategies to prevent and acutely treat stroke in cancer patients are yet to be established. This review summarizes the current evidence on ischemic stroke risk, biomarkers, pathophysiology, treatments, and prognosis in cancer patients, emphasizing knowledge gaps and the potential strategies to address them. Ann Neurol 2018;83:873-883.
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Affiliation(s)
- Babak B Navi
- Department of Neurology
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Costantino Iadecola
- Department of Neurology
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
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Grazioli S, Paciaroni M, Agnelli G, Acciarresi M, Alberti A, D'Amore C, Caso V, Venti M, Guasti L, Ageno W, Squizzato A. Cancer-associated ischemic stroke: A retrospective multicentre cohort study. Thromb Res 2018; 165:33-37. [PMID: 29558659 DOI: 10.1016/j.thromres.2018.03.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 03/07/2018] [Accepted: 03/13/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND The association between stroke and cancer is well-known but insufficiently investigated. Aim of this multicentre retrospective cohort study was to estimate the prevalence of cancer-associated ischemic stroke, describe clinical outcomes in patients with cancer-associated ischemic stroke and investigate independent factors associated with active cancer. METHODS Consecutive adult patients admitted for acute ischemic stroke were included. Included patients were admitted in the Stroke Unit of the Hospital of Perugia, Italy, from March 2005 to March 2015, and in a medical unit of the Hospital of Varese, Italy, from January 2010 till December 2011. Clinical and laboratory data of patients with and without active cancer were collected. Multivariate logistic regression analysis was performed to identify independent factors associated with active cancer. RESULTS A total of 2209 patients admitted with acute ischemic stroke were included with a median hospital stay of 9 days (interquartile range 5.75-14). Mean age was 72.7 years (standard deviation +/- 13); 55% patients were male and 4.4% had active cancer. Factors significantly associated with the presence of active cancer were age > 65 years (odds ratio [OR] 3.34; 95% confidence interval [CI] 1.64-6.81), occurrence of venous thromboembolism [VTE] (OR 2.84; 95% CI 1.12-7.19), low-density lipoprotein (LDL) cholesterol level < 70 mg/dL (OR 1.92; 95% CI 1.06-3.47), cryptogenic stroke subtype (OR 1.93; 95% CI 1.22-3.04). Overall mortality rate during hospital stay was greater in patients with active cancer (21.5% vs. 10% P < 0.05). CONCLUSIONS Older age, occurrence of VTE, low LDL level, and cryptogenic stroke subtype, are independently associated with active cancer. Overall, our findings suggest a possible prevalent role of hypercoagulability in the pathogenesis of cancer-associated ischemic stroke.
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Affiliation(s)
- Stefano Grazioli
- Internal Medicine, Ospedale S.Antonio Abate, ASST Valle Olona, Gallarate, Italy.
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - Giancarlo Agnelli
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - Monica Acciarresi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - Andrea Alberti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - Cataldo D'Amore
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - Michele Venti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - Luigina Guasti
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Walter Ageno
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Achiha T, Takagaki M, Oe H, Sakai M, Matsui H, Nakanishi K, Ozaki T, Fujimoto Y, Yoshimine T, Nakanishi K, Kinoshita M. Voxel-Based Lesion Mapping of Cryptogenic Stroke in Patients with Advanced Cancer: A Detailed Magnetic Resonance Imaging Analysis of Distribution Pattern. J Stroke Cerebrovasc Dis 2017; 26:1521-1527. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.02.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 02/18/2017] [Accepted: 02/26/2017] [Indexed: 11/16/2022] Open
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Parikh NS, Burch JE, Kamel H, DeAngelis LM, Navi BB. Recurrent Thromboembolic Events after Ischemic Stroke in Patients with Primary Brain Tumors. J Stroke Cerebrovasc Dis 2017. [PMID: 28647417 DOI: 10.1016/j.jstrokecerebrovasdis.2017.05.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Stroke mechanisms and the risk of recurrent thromboembolism are incompletely understood in patients with primary brain tumors. We sought to better delineate these important clinical features. METHODS We performed a retrospective cohort study of adults with primary brain tumors diagnosed with magnetic resonance imaging-confirmed acute ischemic stroke at the Memorial Sloan Kettering Cancer Center from 2005 to 2015. Study neurologists collected data on patients' cancer history, stroke risk factors, treatments, and outcomes. Stroke mechanisms were adjudicated by consensus. The primary outcome was recurrent thromboembolism (arterial or venous) and the secondary outcome was recurrent ischemic stroke. Kaplan-Meier statistics were used to calculate cumulative outcome rates, and Cox hazards analysis was used to evaluate the association between potential risk factors and outcomes. RESULTS We identified 83 patients with primary brain tumors and symptomatic acute ischemic stroke. Median survival after index stroke was 2.2 years (interquartile range, .5-7.0). Tumors were mostly gliomas (72%) and meningiomas (13%). Most strokes were from unconventional mechanisms, particularly radiation vasculopathy (36%) and surgical manipulation (18%). Small- or large-vessel disease or cardioembolism caused 13% of strokes, whereas 29% were cryptogenic. Cumulative recurrent thromboembolism rates were 11% at 30 days, 17% at 180 days, and 27% at 365 days, whereas cumulative recurrent stroke rates were 5% at 30 days, 11% at 180 days, and 13% at 365 days. We found no significant predictors of outcomes. CONCLUSION Patients with primary brain tumors generally develop strokes from rare mechanisms, and their risk of recurrent thromboembolism, including stroke, is high.
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Affiliation(s)
- Neal S Parikh
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Jaclyn E Burch
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, New York; Clinical and Translational Neuroscience Unit, Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Lisa M DeAngelis
- Department of Neurology, Weill Cornell Medicine, New York, New York; Clinical and Translational Neuroscience Unit, Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York; Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak B Navi
- Department of Neurology, Weill Cornell Medicine, New York, New York; Clinical and Translational Neuroscience Unit, Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York; Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York.
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Intravenous Thrombolysis in Acute Ischemic Stroke with Active Cancer. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4635829. [PMID: 28660209 PMCID: PMC5474258 DOI: 10.1155/2017/4635829] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/18/2017] [Accepted: 05/14/2017] [Indexed: 11/18/2022]
Abstract
Ischemic stroke patients with active cancer are known to have poor clinical outcomes. However, the efficacy and safety of intravenous alteplase (IV t-PA) in this group are still unclear. In this study, we aimed to evaluate whether stroke patients with cancer had poor clinical outcomes after use of IV t-PA. We reviewed ischemic stroke patients with active cancer treated with isolated IV t-PA between April 2010 and March 2015 at three national university hospitals from the registry for ischemic stroke in Korea. The clinical outcomes of early neurological deterioration (END), hemorrhagic transformation, in-hospital mortality, 3-month modified Rankin scale (mRS), the National Institutes of Health Stroke Scale (NIHSS) discharge score, and duration of hospitalization were compared. We enrolled a total of 12 patients, and the cohort showed poor outcomes including 4 (33%) END events, 7 (58%) hemorrhagic transformations, 3 (25%) in-hospital mortality cases, and 7 (58%) poor mRS (3-6) scores. Additionally, the cryptogenic stroke group (n = 6) more frequently had high mRS scores (P = 0.043) as well as tendencies for frequent END events, hemorrhagic transformations, in-hospital mortality cases, and higher discharge NIHSS scores without statistical significance. In conclusion, ischemic stroke patients with active cancer, especially those with a cryptogenic mechanism, showed poor clinical outcomes after use of IV t-PA.
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