Changes in Serial D-Dimer Levels Predict the Prognoses of Trousseau's Syndrome Patients

Edoxaban for the treatment of hypercoagulability and cerebral thromboembolism associated with cancer: A randomized clinical trial of biomarker targets

BACKGROUND

This study aimed compare efficacy of edoxaban and enoxaparin upon biomarkers of hypercoagulability in patients with cancer-related embolic stroke of undetermined source (ESUS).

METHODS

In this open-label, randomized, pilot trial, patients with cancer-related ESUS within 30 days of diagnosis were randomly assigned (1:1) to receive edoxaban (60 mg once daily) or enoxaparin (1 mg/kg twice daily) for 90 days. The primary endpoint was interval change of serum D-dimer level between days 0 and 7. The secondary endpoints were microembolic signals detected by transcranial Doppler at 7 and 90 days, the modified Rankin scale score, and stroke recurrence during 90 days. Safety outcomes included major bleeding and all-cause death at 90 days.

RESULTS

Of 303 patients with ischemic stroke and cancer, 40 fully met enrollment criteria and were randomized. Baseline D-dimer levels were numerically higher in the edoxaban group (22.9 ± 15.9 μg/mL vs 16.9 ± 16.9 μg/mL). D-dimer level change (%) between days 0 and 7 was similar in the two groups (53.2 ± 25.7 vs 52.2 ± 52.0; P = 0.11). Microembolic signals were detected in 41.1% and 43.8% at baseline, 41.2% and 42.9% at day 7, and 25.0% and 28.6% at day 90 in the edoxaban and enoxaparin groups, respectively. Non-significantly higher major bleeding (35.0% vs 10.0%, P = 0.06) and 90-day mortality (40.0% vs 25.0%, P = 0.31) were noted in the edoxaban group.

CONCLUSION

Edoxaban and enoxaparin were comparable with respect to the biomarkers of hypercoagulability and cerebral thromboembolism. Larger trials are warranted to compare effects of edoxaban and enoxaparin upon recurrent stroke and major bleeding in patients with cancer-related ESUS.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03570281 (https://clinicaltrials.gov/ct2/show/NCT03570281).

Systematic review and meta-analysis of studies comparing baseline D-dimer level in stroke patients with or without cancer: Strength of current evidence

Objectives

D-dimer levels are increased in stroke and cancer. Cancer patients are at a higher risk of stroke. However, the evidence is unclear if high D-dimer in stroke patients can suggest the diagnosis of concomitant cancer or the development of stroke in a cancer patient. The objective is to assess the evidence available on the baseline D-dimer level in stroke patients with and without cancer.

Materials and Methods

We conducted the systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. We searched PUBMED, Cochrane, ScienceDirect, and Scopus for potentially eligible articles published till June 2023. All the review steps were iterative and done independently by two reviewers. The Newcastle-Ottawa scale tool was used to assess the quality of included studies for case control and cohort studies and the Agency for Healthcare Research and Quality tool for cross-sectional studies. The qualitative synthesis is presented narratively, and quantitative synthesis is shown in the forest plot using the random effects model. I2 of more than 60% was considered as high heterogeneity.

Results

The searches from all the databases yielded 495 articles. After the study selection process, six papers were found eligible for inclusion in the qualitative and quantitative synthesis. In the present systematic review, 2651 patients with ischemic infarcts are included of which 404 (13.97%) patients had active cancer while 2247 (86.02%) did not. The studies included were of high quality and low risk of bias. There were significantly higher baseline D-dimer levels in stroke patients with cancer than in non-cancer patients with a mean difference of 4.84 (3.07-6.60) P < 0.00001.

Conclusion

D-dimer is a simple and relatively non-expensive biomarker that is increased to significant levels in stroke patients, who have cancer and therefore may be a tool to predict through screening for active or occult cancer in stroke patients.

D-Dimer Trends Predict Recurrent Stroke in Patients with Cancer-Related Hypercoagulability

INTRODUCTION

In patients with cancer-associated hypercoagulability (CAH)-related stroke, D-dimer trends after anticoagulant therapy may offer a biomarker of treatment efficacy. The purpose of this study was to clarify the association between D-dimer trends and recurrent stroke after anticoagulant therapy in patients with CAH-related stroke.

METHODS

We performed retrospective cohort study of consecutive patients with CAH-related stroke at two stroke centers from 2011 to 2020. The ratio of posttreatment to pretreatment D-dimer levels (post/pre ratio) was used as an indicator of D-dimer trends after anticoagulant therapy. Fine-Gray models were used to evaluate the association between post/pre ratio and recurrent stroke.

RESULTS

Among 360 acute ischemic stroke patients with active cancer, 73 patients with CAH-related stroke were included in this study. Recurrent stroke occurred in 13 patients (18%) during a median follow-up time of 28 days (interquartile range, 11-65 days). Multivariate analysis revealed that high post/pre ratio was independently associated with recurrent stroke (per 0.1 increase: hazard ratio 2.20, 95% confidence interval 1.61-3.01, p = 0.012).

CONCLUSION

D-dimer levels after anticoagulant therapy were associated with recurrent stroke in CAH-related stroke patients. Patients with neutral trends in high D-dimer levels after anticoagulant therapy were at high risk of recurrent stroke.

Association between three-territory sign and prognosis of acute ischemic stroke patients with malignancy

Background

Multiple cerebral infarcts are usually secondary to cardiogenic embolism, particularly through atrial fibrillation (AF). The three-territory sign (TTS) is an imaging marker that reflects multiple cerebral lesions involving three vascular territories measured by diffusion-weighted imaging (DWI), and the most common etiology is an underlying malignancy. Recent studies have shown that TTS is six times more frequently observed in acute ischemic stroke (AIS) patients with malignancy than in those with AF-related AIS. However, the relevance of TTS to the prognosis of IS patients with malignancy remains unclear.

Methods

Over a 5-year period (May 2016 to 31 June 2021), AIS admissions with DWI were identified from the First Affiliated Hospital of Xi'an Jiaotong University. Patients were divided into two groups according to whether they had malignancy or AF, resulting in a total of 80 patients with known malignancy (malignancy group) and 92 patients with AF (AF group). All DWI images were reviewed to determine the territory lesion count. Demographic, clinical, and laboratory data, together with radiographic examination data and modified Rankin Scale (mRS) score within a year, were collected. The main outcome was the association between TTS and the prognosis of AIS patients with malignancy, analyzed by a multivariate logistic regression model.

Results

A total of 172 patients met the selection criteria, including 17 (21.3%) patients in the malignancy group and 8 (8.7%) patients in the AF group with TTS. Age and sex distributions were similar for AIS patients of malignancy and AF. The TTS was 2.4 times more likely to be observed in AIS patients with malignancy compared to AF-related IS patients. The univariate analysis showed that hypertension (OR = 1.137, 95%CI: 1.002-1.291), D-dimer (OR = 1.328, 95%CI: 1.022-1.726), fibrin degradation product (OR = 1.117, 95%CI: 1.010-1.236), and lactate dehydrogenase (LDH; OR = 1.007, 95%CI: 1.000-1.015) were the risk factors for the high mortality rate. Multivariate analysis showed that TTS was the independent risk factor for mortality in AIS patients with malignancy (adjusted OR: 6.866, 95% CI: 1.371-34.395).

Conclusion

TTS was more frequently observed in AIS patients with malignancy than AF-related AIS and substantially related to high poor outcome (mRS > 2) in AIS patients with malignancy, indicating diagnostic and prognostic value in malignancy-associated hypercoagulation stroke.

Differential Diagnostic Value of Machine Learning-Based Models for Embolic Stroke

Cancer-associated thrombosis (CAT) and atrial fibrillation (AF)-related stroke are two subtypes of acute embolic stroke with distinct lesion patterns on diffusion weighted imaging (DWI). This pilot study aimed to evaluate the feasibility and performance of DWI-based machine learning models for differentiating between CAT and AF-related stroke. Patients with CAT and AF-related stroke were enrolled. In this pilot study with a small sample size, DWI images were augmented by flipping and/or contrast shifting to build convolutional neural network (CNN) predicative models. DWI images from 29 patients, including 9 patients with CAT and 20 with AF-related stroke, were analyzed. Training and testing accuracies of the DWI-based CNN model were 87.1% and 78.6%, respectively. Training and testing accuracies were 95.2% and 85.7%, respectively, for the second CNN model that combined DWI images with demographic/clinical characteristics. There were no significant differences in sensitivity, specificity, accuracy, and AUC between two CNN models (all P = n.s.).The DWI-based CNN model using data augmentation may be useful for differentiating CAT from AF-related stroke.

Cerebral Infarction Caused by Trousseau's Syndrome Associated With Lung Cancer

Background

Lung cancer is one of the common cancers that can cause Trousseau's syndrome. However, there are few reports of cerebral infarction due to Trousseau's syndrome associated with lung cancer. The aim of this study is to investigate the clinical features of lung cancer-related cerebral infarction and effective management practice.

Methods

Japanese patients diagnosed with Trousseau's syndrome-related cerebral infarction associated with lung cancer between August 2012 and November 2021 in our hospital were retrospectively enrolled. Clinical data, treatment, and outcomes of the patients were collected.

Results

Ten patients were enrolled. The median age was 65 years (range: 43 - 84 years). All patients had advanced lung cancer. The histological types were adenocarcinoma (n = 8), pleomorphic carcinoma (n = 1), and small cell lung cancer (n = 1). Recurrent cerebral infarction occurred in six patients. Among four patients who had continued heparin since the initial infarction, recurrence occurred in one. D-dimer was high in all 10 patients at the initial cerebral infarction. D-dimer level at the time of recurrent cerebral infarctions was higher than that at the first cerebral infarctions. Since performance status declined in nine patients, one patient continued anticancer drugs after cerebral infarction. Four patients died within 100 days of the onset of cerebral infarction.

Conclusions

Cerebral infarction of lung cancer-related Trousseau's syndrome has poor prognosis. Heparin may be effective in controlling the condition. In addition, D-dimer may serve as a marker of cancer-related thrombosis.

Clinical features of Trousseau's syndrome with multiple acute ischemic strokes

BACKGROUND

Trousseau's syndrome or migrating thrombophlebitis can cause venous or arterial thrombosis; however, multiple acute ischemic strokes (MAIS) caused by Trousseau's syndrome are rare. The aim of this study was to analyse the clinical features of Trousseau's syndrome with MAIS and to improve the awareness and the knowledge of this disease.

METHODS

Clinical data from fifteen patients who were diagnosed as Trousseau's syndrome with MAIS in Rizhao People's Hospital from January 2017 to April 2020 were collected and analysed. The clinical data included the following: patients' basic information (including gender, age, underlying diseases, and tumour stage), laboratory results, imaging features, treatment regimens, and short-term prognoses were collected.

RESULTS

The mean age was 65.5 years, with thirteen males and two females. Most patients (11/15) had a history of smoking and (or) drinking. The average score of NIHSS was 2.13. 6 of the 15 patients first presented with ischemic stroke and then found the primary tumour. Most common types of primary tumour was lung cancer (11/15), and other types of primary tumour were gastric adenocarcinoma, renal cell carcinoma, oesophageal adenosquamous carcinoma, and cholangiocarcinoma (one in each). All the 15 patients showed different levels of increase of D-dimer. The increase in CRP appears in 10 of the 15 patients. Various tumour markers were increased in the 15 patients, especially for CYFRA-211, all the patients of which were higher than normal. All of the 15 patients had multiple vascular territory lesions in DWI, and most lesions were near the cortex areas. Only 4 of the 15 patients (26.7%) occurred with peripheral venous thrombosis. Thirteen patients were given low molecular heparin for anticoagulant therapy, of which 9 patients were improved in short-term while 4 patients were not.

CONCLUSION

Trousseau's syndrome with MAIS was associated with old-age male, smoking and (or) drinking history, low NIHSS score, increased D-dimer, CRP and tumour markers, and lesions near the cortex areas with multiple vascular territories in DWI. Patients with these features should be alert of malignant tumour. Most common types of primary tumour were lung cancer. Treatment with low molecular heparin may be effective in short term.

EGFR-mutant NSCLC presenting with stroke and massive systemic embolization as the first manifestation: case report

Background

Presentation with massive systemic embolization as the initial manifestation of occult malignancy is infrequent. The standard management of cancer-related arterial thromboembolism has not yet been established.

Case presentation

We described a case of Trousseau’s syndrome resulting in acute ischemic stroke concomitant with multiple embolizations in the spleen and kidney during oral administration of dabigatran for pulmonary embolism preceding the diagnosis of a malignant tumor. A cancer-related hypercoagulable state was suspected because the patient was admitted to the neurology department due to acute ischemic stroke with three territory infarcts on diffusion-weighted imaging (DWI) in the absence of identifiable conventional risk factors and brain vessel narrowing. The patient was subsequently diagnosed with epidermal growth factor receptor (EGFR) mutation–positive non-small-cell lung cancer (NSCLC) (stage IV) with pleural metastasis. Administration of low-molecular-weight heparin followed by long-term dabigatran under effective cancer therapy comprising gefitinib and subsequent chemotherapy did not cause stroke relapse during the 1-year follow-up.

Conclusions

This case suggests that cancer-related hypercoagulability should be considered an important etiology for stroke patients who develop unexplained disseminated acute cerebral infarction without conventional stroke risk factors, especially concomitant with multiple organ embolization. Novel oral anticoagulants may be an alternative therapy for the long-term management of cancer-related arterial thromboembolism under effective cancer therapy.

Multiple cerebral infarction linked to underlying cancer: a review of Trousseau syndrome-related cerebral infarction

Trousseau syndrome is a cancer-associated hypercoagulative state leading to venous or arterial thromboembolic events. Cerebral infarction is the most common result of arterial embolism and the pathogenesis is complicated, mainly associated with hypercoagulation and non-bacterial thrombotic endocarditis. On magnetic resonance imaging, multiple lesions are dispersed in more than two territories of the brain, often simultaneously involving the bilateral anterior and posterior circulation. Elevated plasma levels of D-dimer and fibrinogen degradation products may be seen in these patients. There are high rates of short-term recurrence of stroke and sudden death, highlighting the need for early recognition and appropriate treatment of Trousseau syndrome-associated cerebral infarction.

Suitability of Thrombolysis for Patients With Acute Ischemic Stroke Complicated With Trousseau Syndrome

Intravenous thrombolysis (IVT) improves functional outcome after acute ischemic stroke (AIS) and is the standard first-line treatment; however, it is associated with many complications, including cerebral hemorrhage. Cancer patients are susceptible to thrombotic events – collectively referred to as Trousseau syndrome (TS) – owing to their hypercoagulable state. Here, we describe the case of a 55-year-old male with a history of hypertension for over 10 years who underwent surgery for removal of a cancer of lower esophagus, with no subsequent treatment. Three months later, he was admitted to the emergency department of our hospital with sudden dizziness and incoherent speech. Brain computed tomography revealed multiple cerebral infarctions. The patient was treated by IVT with tissue plasminogen activator (rtPA) after the onset of symptoms, which improved by the end of the treatment. However, a few months later, he experienced a recurrence of cerebral infarction and hemorrhage, which has rarely been reported. The clinical course of this case suggests that the suitability of thrombolysis with rtPA in the acute phase of cerebral infarction complicated with TS should be carefully considered.

Importance of Standard Treatment in Prognosis of Patients with Ovarian Cancer and Associated Cerebral Infarction

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.

Cancer-Related Stroke: An Emerging Subtype of Ischemic Stroke with Unique Pathomechanisms

Systemic cancer and ischemic stroke are common conditions and two of the most frequent causes of death among the elderly. The association between cancer and stroke has been reported worldwide. Stroke causes severe disability for cancer patients, while cancer increases the risk of stroke. Moreover, cancer-related stroke is expected to increase due to advances in cancer treatment and an aging population worldwide. Because cancer and stroke share risk factors (such as smoking and obesity) and treatment of cancer can increase the risk of stroke (e.g., accelerated atherosclerosis after radiation therapy), cancer may accelerate conventional stroke mechanisms (i.e., atherosclerosis, small vessel disease, and cardiac thrombus). In addition, active cancer and chemotherapy may enhance thrombin generation causing stroke related to coagulopathy. Patients with stroke due to cancer-related coagulopathy showed the characteristics findings of etiologic work ups, D-dimer levels, and infarct patterns. In this review, we summarized the frequency of cancer-related stroke among patients with ischemic stroke, mechanisms of stroke with in cancer patients, and evaluation and treatment of cancer-related stroke. We discussed the possibility of cancer-related stroke as a stroke subtype, and presented the most recent discoveries in the pathomechanisms and treatment of stroke due to cancer-related coagulopathy.

Salvage surgery for primary lung cancer complicated with Trousseau's syndrome after chemotherapy: a case report

A 65-year-old man was admitted to our hospital due to an abnormal shadow on chest radiographs. Chest computed tomography (CT) revealed a tumor (diameter: 38 mm × 27 mm) and another small nodule in the left upper lobe of the lung, which were accompanied by lymphangitis of the left upper lobe. The patient underwent a transbronchial lung biopsy, following which he was diagnosed with lung adenocarcinoma. Contrast-enhanced CT and ultrasound imaging revealed bilateral pulmonary artery thrombosis and multiple venous thromboses. He was thus diagnosed with stage IIB lung cancer complicated by Trousseau's syndrome. Chemotherapy was initiated using platinum doublets, while infusions of unfractionated heparin and Xa inhibitor were administered for anticoagulant therapy. Following chemotherapy, the main tumor had shrunk, and his lymphangitis, pulmonary artery thrombosis, and multiple venous thromboses had resolved. We then could perform a left upper lobectomy and lymph node dissection safely.