Occult cancer diagnosed following acute ischemic stroke

Mortality in acute ischemic stroke patients with new cancer diagnosed during the index hospitalization versus after discharge

BACKGROUND

Early diagnosis of previously unknown cancer (i.e., occult cancer) after an acute ischemic stroke (AIS) could result in faster initiation of cancer therapy and potentially improve clinical outcomes. Our study aimed to compare mortality rates between AIS patients with occult cancer diagnosed during the index stroke hospitalization versus those diagnosed after hospital discharge.

METHODS

Among consecutive AIS patients treated at our stroke center from 2015 through 2020, we identified new cancer diagnoses made within the year after the AIS. We used multivariable Cox regression analyses to evaluate the association between the timing of occult cancer diagnosis (during the AIS hospitalization versus after discharge) and long-term survival.

RESULTS

Of 3894 AIS patients with available long-term follow-up data, 59 (1.5 %) were diagnosed with a new cancer within one year after index stroke. Of these, 27 (46 %) were diagnosed during the index hospitalization and 32 (54 %) were diagnosed after discharge. During a median follow-up of 406 days (interquartile range, 89-1073), 70 % (n = 19) of patients whose cancer was diagnosed during hospitalization had died, compared to 63 % (n = 20) of patients whose cancer was diagnosed after discharge (p= 0.58). In our main multivariable model, there was no difference in long-term mortality between patient groups (adjusted hazard ratio, 1.16; 95 % confidence interval, 0.53-2.52; p= 0.71).

CONCLUSIONS

In this analysis, timing of a new cancer diagnosis after AIS did not seem to influence patients' long-term survival. Given the fairly small number of included patients with previously occult cancer, larger multicenter studies are needed to confirm our results.

Malignancy-associated ischemic stroke: Implications for diagnostic and therapeutic workup

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.

Connecting atrial fibrillation to digestive neoplasms: exploring mediation via ischemic stroke and heart failure in Mendelian randomization studies

Background

Notwithstanding the acknowledged interplay between atrial fibrillation (AF) and the emergence of digestive system neoplasms, the intricacies of this relationship remain ambiguous. By capitalizing univariable Mendelian Randomization (MR) complemented by a mediated MR tactic, our pursuit was to elucidate the causative roles of AF in precipitating digestive system malignancies and potential intermediary pathways.

Method

This research endeavor seeks to scrutinize the causal clinical implications of whether genetic predispositions to AF correlate with an increased risk of digestive system malignancies, employing MR analytical techniques. Utilizing a dataset amalgamated from six studies related to AF, encompassing over 1,000,000 subjects, we performed univariable MR assessments, employing the random-effects inverse-variance weighted (IVW) methodology as our principal analytical paradigm. Subsequently, a mediated MR framework was employed to probe the potential mediating influence of AF on the nexus between hypertension (HT), heart failure (HF), ischemic stroke (IS), coronary artery disease (CAD), and digestive system neoplasms.

Result

The univariable MR evaluation unveiled a notable causal nexus between the genetic inclination toward AF and the genetic susceptibility to colon, esophageal, and small intestine malignancies. The mediated MR scrutiny ascertained that the genetic inclination for AF amplifies the risk profile for colon cancer via IS pathways and partially explains the susceptibility to esophageal and small intestine tumors through the HF pathway.

Conclusion

Our investigative endeavor has highlighted a definitive causative association between genetic inclination to AF and specific digestive system neoplasms, spotlighting IS and HF as instrumental mediators. Such revelations furnish pivotal perspectives on the complex genetic interconnections between cardiovascular anomalies and certain digestive tract tumors, emphasizing prospective therapeutic and diagnostic worthy of pursuit.

Embolic Stroke of Undetermined Source: Current Perspectives on Diagnosis, Investigations, and Management

In 2014, Hart et al. introduced the concept of "embolic stroke of undetermined source" (ESUS) to the clinical-research stroke community. The hypothesis underlying the development of the ESUS construct was that this potentially heterogenous group of stroke mechanisms were largely thromboembolic, and would thus benefit from anticoagulation over antiplatelet for secondary prevention. Since then, 2 large clinical trials have shown that, to date, there is not a clear uniform antithrombotic strategy for secondary prevention after ESUS as it was originally broadly defined. However, this work has yielded valuable information about the patient phenotypes that experience ESUS strokes, as well as hypothesis-generating substudies that have given rise to the next generation of secondary prevention trials aimed at more personalized approaches for different suspected mechanisms of embolic stroke. In parallel with the evolution of ESUS, several studies aimed at screening for atrial fibrillation in the secondary stroke prevention population have generated additional questions about the mechanistic relevance of atrial fibrillation detected after stroke, and how this should inform poststroke workup, and secondary prevention strategies. Herein, we provide a synthesis of the current understanding surrounding the patient phenotypes that experience ESUS strokes, and previous, ongoing, and anticipated clinical trials that will guide earlier and later secondary prevention strategies and poststroke cardiac investigations.

Qixue Shuangbu decoction and acupuncture combined with Western medicine in acute severe stroke patients

BACKGROUND

Stroke is a common and frequently occurring disease of the nervous system and one of the three major diseases leading to human death. The incidence and mortality of stroke in China increase with age. Overall, 70 % of patients with stroke have serious disability, which results in heavy burden to their families and the society.

AIM

To analyze the effects of Qixue Shuangbu decoction and acupuncture combined with Western medicine on immune indexes and digestive tract function in patients with acute severe stroke.

METHODS

A total of 68 patients with acute severe stroke admitted to Lanzhou Second People’s Hospital between March 2018 and September 2021 were selected and divided into the control and observation groups according to a random number table method. The control group was administered routine Western medicine treatment, such as dehydration, lowering intracranial pressure, anticoagulation, improving cerebral blood circulation and cerebral nerve protection according to the “Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke in China.” The observation group was administered Qixue Shuangbu decoction via nasal feeding tube on the basis of the routine Western medicine treatment with simultaneous acupuncture. The two groups were compared.

RESULTS

The acute physiology and chronic health evaluation II, organ dysfunction syndrome score, National Institutes of Health Stroke Scale, and traditional Chinese medicine syndrome scores of the two groups were significantly decreased compared with those measured before treatment, and the complements C3 and C4, and immunoglobulins (Ig) M and G were significantly increased compared with those observed before treatment (P < 0.05). After treatment, the scores of the observation group were lower than those of the control group, and the complement and Ig levels were higher than those of the control group (P < 0.05). The levels of diamine oxidase (DAO), D-lactic acid (D-LA), and calcitonin gene-related peptide (CGRP) in the two groups were significantly higher than those before treatment, while the levels of lipopolysaccharide, ubiquitin carboxyl-terminal hydrolase 1 (UCH-L1), tumor necrosis factor-α (TNF-α), interleukin (IL) -2, and IL-8 were significantly lower than those before treatment (P < 0.05). After treatment, DAO, D-LA, and CGRP were higher in the observation group than in the control group, while lipopolysaccharide, UCH-L1, TNF-α, IL-2, and IL-8 were lower than in the control group (P < 0.05). The hospitalization time of individuals in the observation group was shorter than that of the control group (P < 0.05).

CONCLUSION

Qixue Shuangbu decoction and acupuncture combined with Western medicine for the treatment of acute severe stroke can regulate intestinal flora, reduce inflammation, improve intestinal mucosal barrier function and immune function related indicators, and promote recovery.

Cancer and stroke: What do we know and where do we go?

Cancer is an increasingly recognized cause for ischemic stroke, with recent acknowledgement of cancer-related stroke as an emerging stroke subtype with unique pathophysiologic mechanisms. In addition, cancer-related stroke may differ from stroke in the general population as cancer patients may not receive guideline-recommended stroke care, and the occurrence of stroke may also preclude patients from receiving optimal cancer treatments. Due to the high degree of morbidity and mortality associated with both conditions, understanding the relationship between stroke and cancer is crucial. In this narrative review, we discuss the association between cancer and stroke, the unique pathophysiologic mechanisms underlying this phenomenon, treatment options including acute reperfusion therapies and secondary prevention strategies, compare outcomes between cancer-related stroke and stroke in the general population, and review new and emerging evidence in this field.

Incidence of stroke in the first year after diagnosis of cancer-A protocol for systematic review and meta-analysis

INTRODUCTION

There is an increased risk of stroke in patients with cancer-this risk is particularly heightened around the time of cancer diagnosis, although no studies have systematically quantified this risk in the literature. Patients newly diagnosed with cancer without prior stroke represent a highly susceptible population in whom there is a window of opportunity to study and implement primary prevention strategies. Therefore, the objective of this systematic review and meta-analysis is to identify the cumulative incidence of ischemic and hemorrhagic strokes during the first year after a diagnosis of cancer.

METHODS AND ANALYSIS

MEDLINE, EMBASE, and PubMed will be searched with the assistance from a medical information specialist, from 1980 until present. Eligible studies will include observational studies that have enrolled adult patients newly diagnosed with cancer and report outcomes of stroke during the first year of cancer diagnosis. We will exclude all randomized and non-randomized interventional studies. Data on participant characteristics, study design, baseline characteristics, and outcome characteristics will be extracted. Study quality will be assessed using the Newcastle-Ottawa Scale for cohort studies, and heterogeneity will be assessed using the I2 statistic. Pooled cumulative incidence will be calculated for ischemic and hemorrhagic strokes separately using a random-effects model.

ETHICS AND DISSEMINATION

No formal research ethics approval is necessary as primary data collection will not be done. We will disseminate our findings through scientific conference presentations, peer-reviewed publications, and social media/the press. The findings from this review will inform clinicians and patients regarding the risk of stroke in patients newly diagnosed with cancer by quantifying the cumulative incidence of each subtype of stroke during the first year after a diagnosis of cancer. This represents a window of opportunity to implement prevention strategies in a susceptible population.

REGISTRATION ID WITH OPEN SCIENCE FRAMEWORK

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Risk of Cancer Following an Ischemic Stroke in the Canadian Longitudinal Study on Aging

BACKGROUND

Stroke survivors may be at higher risk of incident cancer, although the magnitude and the period at risk remain unclear. We conducted a retrospective cohort study to compare the risk of cancer in stroke survivors to that of the general population.

METHODS

The Canadian Longitudinal Study on Aging is a large population-based cohort of individuals aged 45-85 years when recruited (2011-2015). We used data from the comprehensive subgroup (n = 30,097) to build a retrospective cohort with individual exact matching for age (1:4 ratio). We used Cox proportional hazards models to estimate hazard ratios of new cancer diagnosis with and without a prior stroke.

RESULTS

We respectively included 920 and 3,680 individuals in the stroke and non-stroke groups. We observed a higher incidence of cancer in the first year after stroke that declined afterward (p-value = 0.030). The hazard of new cancer diagnosis after stroke was significantly increased (hazard ratio: 2.36; 95% CI: 1.21, 4.61; p-value = 0.012) as compared to age-matched non-stroke participants after adjustments. The most frequent primary cancers in the first year after stroke were prostate (n = 8, 57.1%) and melanoma (n = 2, 14.3%).

CONCLUSIONS

The hazard of new cancer diagnosis in the first year after an ischemic stroke is about 2.4 times higher as compared to age-matched individuals without stroke after adjustments. Surveillance bias may explain a portion of post-stroke cancer diagnoses although a selection bias of healthier participants likely led to an underestimation of post-stroke cancer risk. Prospective studies are needed to confirm the potentially pressing need to screen for post-stroke cancer.