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Knepp B, Navi BB, Rodriguez F, DeAngelis LM, Elkind MSV, Iadecola C, Sherman CP, Tagawa ST, Saxena A, Ocean AJ, Hull H, Jickling G, Sharp FR, Ander BP, Stamova B. Ischemic Stroke with Comorbid Cancer Has Specific miRNA-mRNA Networks in Blood That Vary by Ischemic Stroke Mechanism. Ann Neurol 2024. [PMID: 38874304 DOI: 10.1002/ana.26997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVE Approximately half of ischemic strokes (IS) in cancer patients are cryptogenic, with many presumed cardioembolic. We evaluated whether there were specific miRNA and mRNA transcriptome architectures in peripheral blood of IS patients with and without comorbid cancer, and between cardioembolic versus noncardioembolic IS etiologies in comorbid cancer. METHODS We studied patients with cancer and IS (CS; n = 42), stroke only (SO; n = 41), and cancer only (n = 28), and vascular risk factor-matched controls (n = 30). mRNA-Seq and miRNA-Seq data, analyzed with linear regression models, identified differentially expressed genes in CS versus SO and in cardioembolic versus noncardioembolic CS, and miRNA-mRNA regulatory pairs. Network-level analyses identified stroke etiology-specific responses in CS. RESULTS A total of 2,085 mRNAs and 31 miRNAs were differentially expressed between CS and SO. In CS, 122 and 35 miRNA-mRNA regulatory pairs, and 5 and 3 coexpressed gene modules, were associated with cardioembolic and noncardioembolic CS, respectively. Complement, growth factor, and immune/inflammatory pathways showed differences between IS etiologies in CS. A 15-gene biomarker panel assembled from a derivation cohort (n = 50) correctly classified 81% of CS and 71% of SO participants in a validation cohort (n = 33). Another 15-gene panel correctly identified etiologies for 13 of 13 CS-cardioembolic and 11 of 11 CS-noncardioembolic participants upon cross-validation; 11 of 16 CS-cryptogenic participants were predicted cardioembolic. INTERPRETATION We discovered unique mRNA and miRNA transcriptome architecture in CS and SO, and in CS with different IS etiologies. Cardioembolic and noncardioembolic etiologies in CS showed unique coexpression networks and potential master regulators. These may help distinguish CS from SO and identify IS etiology in cryptogenic CS patients. ANN NEUROL 2024.
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Affiliation(s)
- Bodie Knepp
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology, Weill Cornell Medicine, Feil Family Brain and Mind Research Institute, New York, NY, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Fernando Rodriguez
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons and Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Department of Neurology, Weill Cornell Medicine, Feil Family Brain and Mind Research Institute, New York, NY, USA
| | - Carla P Sherman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Weill Cornell Medicine, Feil Family Brain and Mind Research Institute, New York, NY, USA
| | - Scott T Tagawa
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Ashish Saxena
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Allyson J Ocean
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Heather Hull
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Glen Jickling
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, USA
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Frank R Sharp
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Bradley P Ander
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Boryana Stamova
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, USA
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Xie W, Hsu S, Lin Y, Xie L, Jin X, Zhu Z, Guo Y, Chen C, Huang D, Boltze J, Li P. Malignancy-associated ischemic stroke: Implications for diagnostic and therapeutic workup. CNS Neurosci Ther 2024; 30:e14619. [PMID: 38532275 PMCID: PMC10965754 DOI: 10.1111/cns.14619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Patients with malignancies have an increased risk of suffering ischemic stroke via several mechanisms such as coagulation dysfunction and other malignancy-related effects as well as iatrogenic causes. Moreover, stroke can be the first sign of an occult malignancy, termed as malignancy-associated ischemic stroke (MAS). Therefore, timely diagnostic assessment and targeted management of this complex clinical situation are critical. FINDINGS Patients with both stroke and malignancy have atypical ages, risk factors, and often exhibit malignancy-related symptoms and multiple lesions on neuroimaging. New biomarkers such as eicosapentaenoic acid and blood mRNA profiles may help in distinguishing MAS from other strokes. In terms of treatment, malignancy should not be considered a contraindication, given comparable rates of recanalization and complications between stroke patients with or without malignancies. CONCLUSION In this review, we summarize the latest developments in diagnosing and managing MAS, especially stroke with occult malignancies, and provide new recommendations from recently emerged clinical evidence for diagnostic and therapeutic workup strategies.
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Affiliation(s)
- Wanqing Xie
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Szuyao Hsu
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yuxuan Lin
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Lv Xie
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Xia Jin
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Ziyu Zhu
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yunlu Guo
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Caiyang Chen
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Dan Huang
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | | | - Peiying Li
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Clinical Research Center, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Outcomes Research ConsortiumClevelandOhioUSA
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Moxon JV, Calcino A, Kraeuter AK, Phie J, Anderson G, Standley G, Sealey C, Jones RE, Field MA, Golledge J. A case-control comparison of acute-phase peripheral blood gene expression in participants diagnosed with minor ischaemic stroke or stroke mimics. Hum Genomics 2023; 17:106. [PMID: 38007520 PMCID: PMC10676587 DOI: 10.1186/s40246-023-00551-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/11/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND Past studies suggest that there are changes in peripheral blood cell gene expression in response to ischaemic stroke; however, the specific changes which occur during the acute phase are poorly characterised. The current study aimed to identify peripheral blood cell genes specifically associated with the early response to ischaemic stroke using whole blood samples collected from participants diagnosed with ischaemic stroke (n = 29) or stroke mimics (n = 27) following emergency presentation to hospital. Long non-coding RNA (lncRNA), mRNA and micro-RNA (miRNA) abundance was measured by RNA-seq, and the consensusDE package was used to identify genes which were differentially expressed between groups. A sensitivity analysis excluding two participants with metastatic disease was also conducted. RESULTS The mean time from symptom onset to blood collection was 2.6 h. Most strokes were mild (median NIH stroke scale score 2.0). Ten mRNAs (all down-regulated in samples provided by patients experiencing ischaemic stroke) and 30 miRNAs (14 over-expressed and 16 under-expressed in participants with ischaemic stroke) were significantly different between groups in the whole cohort and sensitivity analyses. No significant over-representation of gene ontology categories by the differentially expressed genes was observed. Random forest analysis suggested a panel of differentially expressed genes (ADGRG7 and miRNAs 96, 532, 6766, 6798 and 6804) as potential ischaemic stroke biomarkers, although modelling analyses demonstrated that these genes had poor diagnostic performance. CONCLUSIONS This study provides evidence suggesting that the early response to minor ischaemic stroke is predominantly reflected by changes in the expression of miRNAs in peripheral blood cells. Further work in independent cohorts particularly in patients with more severe stroke is needed to validate these findings and investigate their clinical relevance.
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Affiliation(s)
- Joseph V Moxon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, 4811, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, 4811, Australia
- Centre for Tropical Bioinformatics and Molecular Biology, James Cook University, Townsville, QLD, 4811, Australia
| | - Andrew Calcino
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, 4811, Australia
- Centre for Tropical Bioinformatics and Molecular Biology, James Cook University, Townsville, QLD, 4811, Australia
| | - Ann-Katrin Kraeuter
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, 4811, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, 4811, Australia
- Faculty of Health and Life Sciences, Psychology, Northumbria University, Newcastle Upon Tyne, UK
| | - James Phie
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, 4811, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, 4811, Australia
| | - Georgina Anderson
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, 4811, Australia
| | - Glenys Standley
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, 4811, Australia
| | - Cindy Sealey
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, 4811, Australia
| | - Rhondda E Jones
- Research Division, James Cook University, Townsville, QLD, 4811, Australia
- Tropical Australian Academic Health Centre, Townsville, QLD, 4811, Australia
| | - Matt A Field
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, 4811, Australia
- Centre for Tropical Bioinformatics and Molecular Biology, James Cook University, Townsville, QLD, 4811, Australia
- Immunogenomics Laboratory, Garvan Institute of Medical Research, Darlinghurst, NSW, 2010, Australia
- Menzies School of Health Research, Darwin, NT, 0811, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, 4811, Australia.
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, 4811, Australia.
- Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, QLD, 4811, Australia.
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Yin L, Chen Y, Fu T, Liu L, Xia Q. Identification of candidate blood biomarkers for the diagnosis of septicaemic melioidosis based on WGCNA. ARTIFICIAL CELLS, NANOMEDICINE, AND BIOTECHNOLOGY 2022; 50:252-259. [DOI: 10.1080/21691401.2022.2126490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Li Yin
- Key Laboratory of Tropical Translational Medicine of Ministry of Education, NHC Key Laboratory of Tropical Disease Control, School of Tropical Medicine and The Second Affiliated Hospital, Hainan Medical University, Haikou, PR China
| | - Yuanyuan Chen
- Key Laboratory of Tropical Translational Medicine of Ministry of Education, NHC Key Laboratory of Tropical Disease Control, School of Tropical Medicine and The Second Affiliated Hospital, Hainan Medical University, Haikou, PR China
| | - Tingting Fu
- Key Laboratory of Tropical Translational Medicine of Ministry of Education, NHC Key Laboratory of Tropical Disease Control, School of Tropical Medicine and The Second Affiliated Hospital, Hainan Medical University, Haikou, PR China
| | - Lin Liu
- Key Laboratory of Tropical Translational Medicine of Ministry of Education, NHC Key Laboratory of Tropical Disease Control, School of Tropical Medicine and The Second Affiliated Hospital, Hainan Medical University, Haikou, PR China
| | - Qianfeng Xia
- Key Laboratory of Tropical Translational Medicine of Ministry of Education, NHC Key Laboratory of Tropical Disease Control, School of Tropical Medicine and The Second Affiliated Hospital, Hainan Medical University, Haikou, PR China
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Zhang C, Wang L, Guo Y, Feng W. Systematic analysis of brain and skull ischemic injury expression profiles reveals associations of the tumor immune microenvironment and cell death with ischemic stroke. Front Immunol 2022; 13:1082546. [PMID: 36605216 PMCID: PMC9809284 DOI: 10.3389/fimmu.2022.1082546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 11/23/2022] [Indexed: 01/07/2023] Open
Abstract
Background Previous studies have shown that stroke is a potential first sign of neoplasia, but the relationship between stroke and cancer remains unclear. As a complex brain disease, ischemic stroke involves cell death and immunity. Thus, it is necessary to investigate the association of the tumor immune microenvironment and cell death with ischemic stroke. Methods We established a photothrombosis-induced ischemic injury model in mouse brain and skull. Subsequently, we sequenced the whole transcriptome of the injured mouse brain and skull and analyzed the expression profiles. To investigate the association of stroke with cell death and cancer, we systematically performed gene set enrichment analysis in pan-cell death (i.e., apoptosis, cuproptosis, ferroptosis, necroptosis, and pyroptosis) and the cancer hallmark pathways. The time-dependent immune cell abundance variations after ischemic injury were estimated. Furthermore, pan-cancer genomic and prognostic analyses of the ischemic injury-related gene sets were also performed. Results In this study, we found that there exist temporal and spatial differences in the gene expression patterns of both the brain and skull with ischemic injury. The skull ischemic injury-induced changes in the brain transcriptome were particularly great, but could recover in a short period, while the skull transcriptome variation resulting from brain ischemic injury was long-lasting. In addition, the expression of the genes related to ischemic injury was also associated with pan-cell death and the cancer hallmark pathways. The changes in the abundance of immune cells indicate that brain ischemic injury may disrupt the immune microenvironment for a longer time, while the skull can balance the stability of the immune microenvironment better. Moreover, the brain ischemic injury-related gene sets were highly correlated with a variety of tumors, particularly glioblastoma multiforme (GBM), kidney renal clear cell carcinoma (KIRC), brain lower grade glioma (LGG), and uveal melanoma (UVM), which carry a greater mortality risk after stroke. Conclusion This systematic analysis not only helps in the understanding of the changes in the gene expression profiles of both the brain and skull with ischemic injury but also reveals the association of the tumor immune microenvironment and cell death with ischemic stroke.
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Affiliation(s)
- Chao Zhang
- Zhanjiang Institute of Clinical Medicine, Central People’s Hospital of Zhanjiang, Zhanjiang, Guangdong, China,Zhanjiang Central Hospital, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Lisi Wang
- Zhanjiang Institute of Clinical Medicine, Central People’s Hospital of Zhanjiang, Zhanjiang, Guangdong, China,Zhanjiang Central Hospital, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Yunmiao Guo
- Zhanjiang Institute of Clinical Medicine, Central People’s Hospital of Zhanjiang, Zhanjiang, Guangdong, China,Zhanjiang Central Hospital, Guangdong Medical University, Zhanjiang, Guangdong, China,*Correspondence: Yunmiao Guo, ; Wei Feng, ;
| | - Wei Feng
- Zhanjiang Institute of Clinical Medicine, Central People’s Hospital of Zhanjiang, Zhanjiang, Guangdong, China,Zhanjiang Central Hospital, Guangdong Medical University, Zhanjiang, Guangdong, China,*Correspondence: Yunmiao Guo, ; Wei Feng, ;
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6
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Sener U, Keser Z. Ischemic Stroke in Patients With Malignancy. Mayo Clin Proc 2022; 97:2139-2144. [PMID: 36333017 DOI: 10.1016/j.mayocp.2022.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/05/2022]
Abstract
Approximately one-quarter to one-third of patients with ischemic stroke have an embolic stroke of undetermined source (ESUS). An estimated 5% to 10% of patients with ESUS have an active cancer diagnosis. Presence of cancer potentially increases the risk of acute ischemic stroke through various mechanisms such as cancer-related hypercoagulability, intracranial tumors leading to an arterial compression, or intracardiac tumors leading to cardioembolism. Certain cancer therapeutics can also contribute to risk of ischemic stroke. Multiple vascular lesions involving bilateral anterior and posterior circulations, high plasma D-dimer levels, and elevated inflammatory markers might suggest cancer-related ischemic stroke. Patients with ischemic stroke related to malignancy are also at higher risk of stroke recurrence, early neurologic deterioration, and mortality. Cancer screening in acute ischemic stroke patients can be considered when no other etiology for stroke can be established and clinical history such as tobacco use, unexplained constitutional symptoms such as fever or night sweats, or unexplained weight loss suggests an underlying malignancy. Selection of antithrombotics for secondary stroke prevention remains controversial as clinical trial data for use of antiplatelet therapy vs anticoagulation in ESUS and cancer patients is limited. Future clinical trials should specifically focus on patients with ischemic stroke related to malignancy are needed to guide appropriate therapeutic agent selection.
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Affiliation(s)
- Ugur Sener
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
| | - Zafer Keser
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Hu X, Wang Y, Du W, Liang LJ, Wang W, Jin X. Role of Glial Cell-Derived Oxidative Stress in Blood-Brain Barrier Damage after Acute Ischemic Stroke. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:7762078. [PMID: 36092167 PMCID: PMC9463007 DOI: 10.1155/2022/7762078] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/13/2022] [Indexed: 11/18/2022]
Abstract
The integrity of the blood-brain barrier (BBB) is mainly maintained by endothelial cells and basement membrane and could be regulated by pericytes, neurons, and glial cells including astrocytes, microglia, oligodendrocytes (OLs), and oligodendrocyte progenitor cells (OPCs). BBB damage is the main pathological basis of hemorrhage transformation (HT) and vasogenic edema after stroke. In addition, BBB damage-induced HT and vasogenic edema will aggravate the secondary brain tissue damage. Of note, after reperfusion, oxidative stress-initiated cascade plays a critical role in the BBB damage after acute ischemic stroke (AIS). Although endothelial cells are the target of oxidative stress, the role of glial cell-derived oxidative stress in BBB damage after AIS also should receive more attention. In the current review, we first introduce the physiology and pathophysiology of the BBB, then we summarize the possible mechanisms related to BBB damage after AIS. We aim to characterize the role of glial cell-derived oxidative stress in BBB damage after AIS and discuss the role of oxidative stress in astrocytes, microglia cells and oligodendrocytes in after AIS, respectively.
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Affiliation(s)
- Xiaoyan Hu
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Department of Histology and Embryology, School of Basic Medical Sciences, Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100069, China
| | - Yanping Wang
- Department of Neurology, The Second Hospital of Jiaxing City, Jiaxing, 314000 Zhejiang, China
| | - Weihong Du
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Department of Histology and Embryology, School of Basic Medical Sciences, Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100069, China
| | - Li-Jun Liang
- Children's Hospital of Shanxi Province, Taiyuan, Shanxi Province, China
| | - Wei Wang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, China
| | - Xinchun Jin
- Beijing Key Laboratory of Cancer Invasion and Metastasis Research, Department of Histology and Embryology, School of Basic Medical Sciences, Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100069, China
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From cryptogenic to ESUS: Toward precision medicine? Rev Neurol (Paris) 2022; 178:939-952. [PMID: 35597610 DOI: 10.1016/j.neurol.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/11/2022] [Accepted: 01/18/2022] [Indexed: 11/20/2022]
Abstract
Cryptogenic infarctions are infarctions without a defined cause, despite a complete work-up. They differ from infarctions of undetermined causes, which may involve overlapping causes or an incomplete investigation. It is also different from uncommon heritable and non-heritable causes. The term embolic stroke of undetermined source (ESUS) proposed in 2014 is defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources. The major advantage of this definition compared to cryptogenic definition is the proposition of a specific work-up. In a general population, frequent potential sources of embolism in patients with ESUS have been suggested since a long time and include: patent foramen ovale (PFO), covert atrial fibrillation (AF), complex aortic arch atheroma, large vessel atheroma with stenosis<50%, carotid web, atrial cardiomyopathy, thrombophilia associated with cancer. It took almost 30 years to show, in patients under 60 with a cryptogenic stroke and a PFO, that PFO occlusion was superior to medical treatment alone for recurrent stroke. PFO under 60 is therefore no longer a cryptogenic cause of infarction. The concept of cryptogenic stroke and its refinement in ESUS have been fruitful for the identification of PFO associated as a cause. Covert AF can be detected by different techniques but its risk significance for recurrent stroke might be different from the simple electrocardiographic detection of AF. With the development of direct oral anticoagulants (DOAs), randomized studies in patients with ESUS, were run for stroke prevention but no difference was observed between patients treated by DOA compared to aspirin. These studies showed however the heterogeneity of ESUS patients. Further ESUS classification should be considered as a tool to identify homogeneous groups. We propose to further split the ESUS group into different subgroups: ESU-PFO>60-year-old, ESUS-ATH with stenosis<50%, ESUS-AF (covert AF & atrial cardiomyopathy), ESUS-cancer and others. Precision medicine is the ability to make targeted healthcare decisions based on the specific risks of individual patients. One preliminary stage is therefore to identify homogeneous groups suitable in the future for new therapeutic trials and, at the end, for new specific treatments.
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Kawano T, Sasaki T, Gon Y, Kitano T, Kanki H, Todo K, Shimamura M, Matsumura Y, Huang A, Hattori S, Mochizuki H. High neutrophil/lymphocyte ratio at cancer diagnosis predicts incidence of stroke in cancer patients. Brain Commun 2021; 3:fcab071. [PMID: 33928250 PMCID: PMC8062330 DOI: 10.1093/braincomms/fcab071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2021] [Indexed: 01/09/2023] Open
Abstract
Although cancer increases the incidence and severity of ischaemic stroke, there is no reliable method for predicting ischaemic stroke in cancer patients. To evaluate the prognostic capacity of the neutrophil-to-lymphocyte ratio at cancer diagnosis for predicting the incidence of ischaemic stroke, we used a hospital-based cancer registry that contained clinical data from all patients treated for cancer at Osaka University Hospital between 2007 and 2015. The neutrophil-to-lymphocyte ratio was calculated after dividing absolute neutrophil counts by absolute lymphocyte counts. These counts were obtained within 1 month after cancer diagnosis. The primary endpoint was new-onset ischaemic stroke within 2 years after cancer diagnosis. Of the 18 217 included cancer patients (median age: 65.2 years), 69 (0.38%) had ischaemic stroke. Unadjusted Cox regression analysis stratified by cancer site demonstrated that each 1-unit increase in the neutrophil-to-lymphocyte ratio was associated with a significant 7.2% increase in the risk of an ischaemic stroke event (95% confidence interval 1.041–1.103, P < 0.001). Survival tree analysis and the Kaplan–Meier method suggested that patients with and without atrial fibrillation who had increased neutrophil-to-lymphocyte ratios had a higher risk of ischaemic stroke. Multivariate Cox proportional hazard models, adjusted for cancer site and stage, revealed that patients with high neutrophil-to-lymphocyte ratios (>15) had higher ischaemic stroke risk than patients with low neutrophil-to-lymphocyte ratios (<5). This was true among cancer patients both with (hazard ratio 11.598; 95% confidence interval 0.953–141.181) and without (hazard ratio 7.877; 95% confidence interval 2.351–26.389) atrial fibrillation. The neutrophil-to-lymphocyte ratio at cancer diagnosis is associated with the incidence of ischaemic stroke among cancer patients and might thus be useful for identifying patients at high risk of ischaemic stroke, allowing us to guide future preventive interventions.
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Affiliation(s)
- Tomohiro Kawano
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Yasufumi Gon
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Takaya Kitano
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Hideaki Kanki
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Munehisa Shimamura
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan.,Department of Health Development and Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Yasushi Matsumura
- Department of Medical Informatics Science, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Ao Huang
- Department of Biomedical Statistics, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Satoshi Hattori
- Department of Biomedical Statistics, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan.,Open and Transdisciplinary Research Initiatives, Osaka University, Suita, Osaka, 565-0871, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
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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: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
One-quarter to one-third of ischemic strokes have no established mechanism after standard diagnostic evaluation and are classified as embolic stroke of undetermined source (ESUS). Failure of randomized trials to demonstrate a benefit of direct oral anticoagulants over aspirin for the treatment of ESUS as a single homogeneous entity has led to renewed interest by stroke experts to divide ESUS into subgroups. Emerging data suggest that active cancer, which is present in 5% to 10% of patients with ESUS, is a distinct and important subgroup of ESUS with unique clinical characteristics, underlying pathophysiologies, and treatment and prognostic considerations. Furthermore, the prevalence of cancer-related ESUS is expected to increase as patients with cancer, even those with distant metastases, survive longer due to improvements in cancer treatments. In this topical review, we examine the epidemiological link between ESUS and cancer, the clinical features and potential mechanistic underpinnings of ESUS with cancer (with a focus on novel biomarkers and their relationship to recurrent stroke and other thromboembolic events), and the potential treatment strategies for cancer-related ESUS. We include a critical appraisal of existing data and ongoing or planned clinical trials of different antithrombotic approaches. As cancer-related ESUS is a dynamic disease with variable course, we recommend close collaboration between neurologists and oncologists to develop individualized management plans.
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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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Huang T, Li Y, Zhou Y, Lu B, Zhang Y, Tang D, Gan Y, He Z, Chen Z, Yu W, Li P. Stroke Exacerbates Cancer Progression by Upregulating LCN2 in PMN-MDSC. Front Immunol 2020; 11:299. [PMID: 32153594 PMCID: PMC7050632 DOI: 10.3389/fimmu.2020.00299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 02/06/2020] [Indexed: 12/20/2022] Open
Abstract
Acute ischemic stroke (AIS) is common in patients with cancer, and mounting clinical evidence suggests that it may shorten the survival of cancer patients. But how stroke affects the progression of cancer remains unclear. We inoculated B16 tumor cells (2 × 105) subcutaneously before distal middle cerebral artery occlusion (dMCAO) or sham surgery in C57BL/6 mice and found that compared to sham operated mice, dMCAO mice developed significantly increased tumor volume and were accompanied by lower survival rate. To explore the underlying mechanism, we performed RNA-sequencing analysis of the tumor tissue from mice with or without stroke and found prominent upregulation of lipocalin 2 (LCN2) in the tumor from stroke mice compared to those from sham mice. Using quantitative reverse transcription-PCR, we confirmed increased mRNA expression of LCN2 as well as anti-inflammatory cytokines-Arg1, IL-10, and decreased mRNA level of pro-inflammatory cytokines-IL-6, IL-23 in the tumor of cancer-bearing stroke mice. Both immunofluorescence staining and flow cytometry analysis revealed that increased expression of LCN2 was mainly derived from the polymorphonuclear myeloid derived suppressor cells (PMN-MDSCs) in the tumor. We also found that stroke reduced the PMN-MDSCs in the peripheral blood, but increased PMN-MDSCs in the tumor of the cancer-bearing mice after stroke. In conclusion, cerebral ischemic stroke may exacerbate cancer progression by increasing LCN2 expression in PMN-MDSCs, which turns out to be a promising therapeutic target to suppress cancer progression after ischemic stroke.
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Affiliation(s)
- Tingting Huang
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Yan Li
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Yuxi Zhou
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Bingwei Lu
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Yueman Zhang
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Dan Tang
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Yu Gan
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Zhengzhou He
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Zengai Chen
- Department of Radiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
| | - Peiying Li
- Department of Anesthesiology, Renji Hospital, School of Medicine Shanghai Jiaotong University, Shanghai, China
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