Ischemic stroke and cancer: stroke severely impacts cancer patients, while cancer increases the number of strokes

Clinical features and prognostic factors of patients with cancer-associated stroke

BACKGROUND

Cerebrovascular diseases in cancer patients significantly aggravate their condition and prognosis; therefore, prompt and accurate diagnosis and treatment are important. The purpose of this study was to investigate patient demographics, laboratory data, brain magnetic resonance imaging (MRI) findings, and prognosis among patients with stroke and cancer, especially cancer-associated ischemic stroke (CAIS).

METHODS

We performed a retrospective, single-center study. We enrolled consecutive patients who had acute stroke and were admitted to our hospital between January 2011 and December 2021. We collected general demographic characteristics, cancer histopathological type, laboratory data, brain MRI findings, and prognosis data.

RESULTS

Among 2040 patients with acute stroke, a total of 160 patients (7.8%) had active cancer. The types of strokes were cerebral infarction, cerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack in 124, 25, 5, and 6 patients, respectively. Among the patients with ischemic stroke, there were 69 cases of CAIS. Pancreas and adenocarcinoma were the most frequent types of primary tumor and histopathology. Patients with adenocarcinoma and those with cerebral infarctions in both bilateral anterior and posterior cerebral circulation areas showed higher D-dimer levels. Pancreatic cancer and high plasma D-dimer levels were associated with poor survival rate.

CONCLUSION

CAIS was seen more frequently in patients with pancreatic cancer and adenocarcinoma. Pancreatic cancer and high plasma D-dimer levels were potential factors of poor prognosis in patients with CAIS.

Malignant tumor increases the risk of all causes in-hospital mortality in critically ill patients with ischemic stroke: analysis of the MIMIC-IV database

BACKGROUND

Ischemic stroke (IS) and malignant tumor (MT) have high morbidity and mortality rates worldwide, and several associations exist between them. This study aimed to determine the effect of MT on hospital mortality in patients with IS.

METHODS

Based on their MT status, participants with IS in the Medical Information Mart for Intensive Care IV (MIMIC-IV) were divided into two groups. The primary outcome was in-hospital all causes mortality. Kaplan-Meier survival analysis was performed to evaluate the intergroup in-hospital mortality, and three Cox regression models were used to determine the association between MT and in-hospital mortality.

RESULTS

A total of 1605 participants (749 males and 856 females) were included in the study. The mean age was 72.030 ± 15.463 years. Of these, 257 (16%) patients died in the hospital. Kaplan-Meier analysis showed that the MT group had a significantly lower possibility of in-hospital survival than the non-MT group. In the unadjusted model, in-hospital mortality among MT patients had a higher odds ratio (OR) of 1.905 (95% CI, 1.320-2.748; P < 0.001) than the non-MT group. After adjusting for basic information, vital signs, and laboratory data, MT was also associated with increased in-hospital mortality (OR = 1.844, 95% CI: 1.255-2.708; P = 0.002).

CONCLUSIONS

Among the patients with IS, the risk of all causes in-hospital mortality was higher for MT than for patients non-MT. This finding can assist clinicians in more accurately assessing prognosis and making informed treatment decisions.

A case of Trousseau syndrome: Screening, detection and complication

Trousseau syndrome (TS) is a malignant tumor-mediated complication of the hypercoagulable state with an unknown etiology. Laboratory testing results in patients with TS have indicated elevated D-dimer levels. The imaging analysis in patients who had undergone stroke has shown the presence of several cerebral infarction lesions in multiple regions. Since patients have had malignant tumors for a long time when they suffer from a secondary stroke, the optimum time for radical tumor treatment is usually missed. This study reports a case to improve the early screening and detection of TS and reduce the risk of recurrence of cerebral infarction.

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.

Association between cancer, CHA2DS2VASc risk, and in-hospital ischaemic stroke in patients hospitalized for atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is commonly encountered in cancer patients. We investigated the CHA2DS2VASc score, and its association with in-hospital ischaemic stroke in patients with cancer who were hospitalized for AF.

METHODS AND RESULTS

Using the United States National Inpatient Sample, all hospitalizations with principal diagnosis of AF between October 2015 and December 2018 were stratified by cancer diagnosis, type, and CHA2DS2VASc risk categories (low risk, low-moderate risk, moderate-high risk). In-hospital ischaemic stroke and its association with the CHA2DS2VASc risk score was assessed across the groups using hierarchical multivariable logistic regression with adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). Discrimination of CHA2DS2VASc score for in-hospital ischaemic stroke was evaluated with Receiver Operating Characteristic and Area Under the Curve (AUC). Among 1 341 870 included hospitalizations, 71 965 (5.4%) had comorbid cancer. Cancer patients had a higher proportion of moderate-high CHA2DS2VASc risk compared with their non-cancer counterparts (86.5% vs. 82.3%, P < 0.001). Compared with their low CHA2DS2VASc risk counterparts, cancer patients in low-moderate and moderate-high risk scores had similar odds of developing stroke (aOR 1.28 95% CI 0.22-7.63 and aOR 1.78 95% CI 0.41-7.66, respectively). The CHA2DS2VASc risk score had poor discrimination for ischaemic stroke in the cancer group (AUC 0.538 95% CI 0.477-0.598).

CONCLUSION

Cancer patients with AF have high CHA2DS2VASc risk. Discrimination of CHA2DS2VASc for ischaemic stroke is lower in cancer than non-cancer patients, and CHA2DS2VASc may not be adequate in determining ischaemic risk in cancer population.

Outcomes and Discriminatory Accuracy of the CHA2DS2VASc Score in Atrial Fibrillation and Cancer

Background

Atrial fibrillation (AF) is highly prevalent among cancer patients. The role of traditional risk stratification scores in the context of different cancer types in these patients remains unknown.

Objectives

The purpose of this study was to determine the discriminative accuracy of the CHA2DS2VASc score for ischemic stroke using receiver operating characteristic and area under the curve.

Methods

The National Readmission Database (2015-2019) was used to identify all AF patients stratified by the cancer diagnosis, type, and CHA2DS2VASc category (low; moderate; high risk). Outcomes at 30-day readmission were compared between cancer and noncancer groups using hierarchical multivariable logistic regression to calculate adjusted odds ratios (aORs) and 95% CIs.

Results

A total of 6,996,088 AF patients were identified at index admission. Of these, 4,242,630 (642,237 cancer, 3,600,393 noncancer) were readmitted at 30 days. Cancer patients (92.1%) had a higher proportion of high CHA2DS2VASc scores compared with their noncancer counterparts (89.8%, P < 0.001). The 30-day readmission rate and incidence of major bleeding in cancer patients were significantly higher compared with their corresponding noncancer group across all CHA2DS2VASc categories. Among the different cancer types, hematological and lung cancer had a high propensity for major bleeding. The odds of ischemic stroke were lower in the cancer group across high (1.9% vs 2.4%; aOR: 0.78; 95% CI: 0.76-0.79; P < 0.0001), moderate (0.8% vs 1.3%; aOR: 0.57; 95% CI: 0.50-0.64; P < 0.0001), and low (0.4% vs 0.9%; aOR: 0.46; 95% CI: 0.34-0.62; P < 0.0001) risk category relative to the noncancer group irrespective of type of cancer. CHA2DS2VASc category had a statistically significant discriminatory accuracy for ischemic stroke in both cancer and noncancer patients.

Conclusions

Cancer patients with AF are at a higher risk of readmission and major bleeding. The risk of ischemic stroke during readmission appears to be lower than noncancer patients. These findings may have implications for anticoagulant therapy in cancer patients.

Non-Hypertensives and Those with Normal Cholesterol Are More Likely to Have Concomitant Cancer amongst Patients with Ischemic Stroke: A Retrospective Cross-Sectional Registry-Based Study

INTRODUCTION

Patients with cancer are known to have an increased risk of ischemic stroke (IS) around the time of their diagnosis. However, there is a paucity of data in Asian populations, and as such, we aimed to determine cancer incidence rates and patterns in Asian IS patients as well as investigate the differences in vascular risk profile of IS patients with and without concomitant cancer.

METHODS

We conducted a retrospective cross-sectional study using data from the Singapore Stroke and Cancer registries. We defined cases as patients with IS and a cancer diagnosis 2 years before or after the index IS. Cancer incidence was determined using the same direct age-standardization method performed for the Singapore general population in the 2015 Singapore cancer report. Multivariable logistic regression was used to analyze differences in vascular risk factors.

RESULTS

Among 21,068 IS patients (mean age, 67.9 ± 13.3 years), 6.3% (1,330) were found to have concomitant cancer; 4.4% (935) had prior cancer while 1.8% (395) had cancer diagnoses within 2 years following IS. The cancer incidence among IS patients was 3,393 (95% confidence interval [CI], 1,937-4,849) per 100,000 person-years compared to 219-231 per 100,000 person-years in the general population. Older age (odds ratio [OR], 1.02 [95% CI, 1.01-1.02] per year), males (OR, 1.25 [95% CI, 1.11-1.41), Chinese ethnicity (OR, 1.61 [95% CI, 1.37-1.89]) and a lower prevalence of hypertension (OR, 0.84 [95% CI, 0.73-0.97)]), and hyperlipidemia (OR, 0.53 [95% CI, 0.45-0.62]) were independently associated with cancer-related IS.

CONCLUSIONS

The age-standardized cancer incidence was 15 times higher in IS patients than the general population. IS patients with concomitant cancer were older and had a lower prevalence of vascular risk factors.

The crosstalk between Stroke and Cancer: Incidence of cancer after a first-ever cerebrovascular event in a population-based study

OBJECTIVES

To determine the cancer incidence after the first-ever cerebrovascular event (CVE) and compare it to the cancer incidence in the population from the same region.

METHODS

We evaluated 1069 patients with a first-ever CVE (Ischaemic or haemorrhagic stroke and Transient Ischaemic Attack) from a prospective population registry of stroke and transient focal neurological attacks, diagnosed between 2009 and 2011. We conducted a structured search to identify cancer-related variables and case-fatality for a period of 8 years following CVE. Cancer incidence in CVE patients was compared to the North Region Cancer Registry (RORENO).

RESULTS

We found that 90/1069 (8.4%) CVE patients developed cancer after a first-ever CVE. Overall cancer annual incidence rate was higher after a CVE (820/100,000, 95%CI: 619-1020) than in general population (513/100,000, 95%CI: 508-518). In the 45-54 age group cancer incidence post-CVE was 3.2-fold (RR, 95%CI: 1.6-6.4) higher compared to the general population, decreasing gradually in older age-groups. Median time between CVE and cancer was 3.2 years (IQR = 1.4-5.2). Lower respiratory tract and colorectal were the most frequent cancer types. In univariable models, male sex (sHR = 1.78, 95%CI: 1.17-2.72, p = 0.007), tobacco use (sHR = 2.04, 95%CI: 1.31-3.18, p = 0.002) and peripheral artery disease (sHR = 2.37, 95%CI: 1.10-5.13, p = 0.028) were associated to higher cancer risk after CVE. After adjustment, tobacco use (sHR = 1.84, 95%CI: 1.08-3.14, p = 0.026) remained associated to a higher risk of cancer.

CONCLUSIONS

At the population level, patients presenting a first-ever CVE have higher cancer incidence, that is particularly prominent in younger age-groups. Higher cancer incidence, delayed cancer diagnosis and increased mortality post-CVE warrants further research on long-term cancer surveillance in first-ever CVE survivors.

Clinical significance of D-dimer levels during acute period in ischemic stroke

BACKGROUND

Initial D-dimer level is a well-known prognostic parameter in patients with acute ischemic stroke (AIS). However, there have been no studies on the clinical significance of follow-up D-dimer levels. In this study, we evaluated the association between initial and follow-up D-dimer levels and early neurological deterioration (END) in patients with AIS.

METHODS

We included consecutive patients with AIS who had a positive initial D-dimer test (> 0.55 mg/L) between March 2021 and November 2022. The follow-up D-dimer test was performed on the 7th day after hospitalization and on the day of discharge if discharged earlier. END was defined as an increase of ≥ 2 in the total NIHSS score, or ≥ 1 in the motor NIHSS score within the first 7 days of admission. As medical conditions closely associated with the initial and follow-up D-dimer levels in AIS patients, we also evaluated the history of cancer, active cancer, and venous thromboembolism (VTE) that occurred during hospitalization together.

RESULTS

A total of 246 patients with AIS were evaluated (median age: 87 years, male: 56.5%). In multivariable logistic regression analysis, the initial D-dimer level was closely associated with END after adjusting for confounders (adjusted odds ratio [aOR]: 1.48, 95% CI: 1.06-2.05). The follow-up D-dimer level also showed a close correlation with END (aOR: 1.60, 95% CI: 1.16-2.20). Regarding the analysis of the association between D-dimer levels and underlying cancer or VTE, the initial D-dimer level showed a statistically significant positive relationship only with active cancer (P = 0.024). On the other hand, the follow-up D-dimer level was found to be statistically significantly associated with a history of cancer (P = 0.024), active cancer (P = 0.001), and VTE (P = 0.001).

CONCLUSIONS

Initial and follow-up D-dimer levels were associated with END in AIS patients. Particularly, the follow-up D-dimer level showed a clear correlation not only with END but also with the underlying cancer or the occurrence of VTE during the acute period.

Bleeding risk and mortality according to antithrombotic agents' exposure in cancer-related stroke patients: nationwide population-based cohort study in South Korea

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.

Acute Ischemic Stroke in Tubercular Meningitis Patients Without Conventional Vascular Risk Factors: A Retrospective Case Control Study

Objective

Ischemic stroke is a common complication in patients with tubercular meningitis (TBM). However, the risk factors for Ischemic stroke in TBM patients are not fully understood, especially in those patients without conventional vascular risk factors. The aim of the present study was to explore the clinical features and independent risk factors for tubercular meningitis-related Ischemic stroke (TBMRIS).

Methods

Tubercular meningitis patients with acute Ischemic stroke without conventional vascular risk factors were recruited between July 2010 and July 2020 as the TBMRIS group. Patients who solely had tubercular meningitis were recruited as the control group (TMB group). Demographic characteristics, clinical presentations, and cerebrospinal fluid (CSF) examinations were collected, and multiple logistic regression analysis was applied to analyse the independent risk factors for TBMRIS.

Results

A total of 70 TBMRIS patients and 70 TMB patients were enrolled. Most (82.86%) of the TBMRIS patients experienced Ischemic stroke events within 3 months after the diagnosis of tubercular meningitis. The multiple logistic regression analysis revealed that variation in red blood cell distribution width (RDW-CV), mean platelet volume (MVP), C-reactive protein (CRP), CSF glucose and Modified Research Council Grade II (MRC Grade II) were independent risk factors for TBRIS. The AUC of the identification model was 0.808, with a sensitivity of 68.60% and a specificity of 84.30%.

Conclusion

This study revealed that RDW-CV, MVP, CRP, CSF glucose and MRC Grade II are potential independent risk factors for TBMRIS. The identification model established in this study may help monitor TBM patients who are at high risk of developing TBMRIS.

Cancer and stroke: commonly encountered by clinicians, but little evidence to guide clinical approach

The association between stroke and cancer is well-established. Because of an aging population and longer survival rates, the frequency of synchronous stroke and cancer will become even more common. Different pathophysiologic mechanisms have been proposed how cancer or cancer treatment directly or via coagulation disturbances can mediate stroke. Increased serum levels of D-dimer, fibrin degradation products, and CRP are more often seen in stroke with concomitant cancer, and the clot retrieved during thrombectomy has a more fibrin- and platelet-rich constitution compared with that of atherosclerotic etiology. Multiple infarctions are more common in patients with active cancer compared with those without a cancer diagnosis. New MRI techniques may help in detecting typical patterns seen in the presence of a concomitant cancer. In ischemic stroke patients, a newly published cancer probability score can help clinicians in their decision-making when to suspect an underlying malignancy in a stroke patient and to start cancer-screening studies. Treating stroke patients with synchronous cancer can be a delicate matter. Limited evidence suggests that administration of intravenous thrombolysis appears safe in non-axial intracranial and non-metastatic cancer patients. Endovascular thrombectomy is probably rather safe in these patients, but probably futile in most patients placed on palliative care due to their advanced disease. In this topical review, we discuss the epidemiology, pathophysiology, and prognosis of ischemic and hemorrhagic strokes as well as cerebral venous thrombosis and concomitant cancer. We further summarize the current evidence on acute management and secondary preventive therapy.

Evaluation of right-to-left shunt on contrast-enhanced transcranial Doppler in patent foramen ovale-related cryptogenic stroke: Research based on imaging

BACKGROUND

Cardiogenic embolism caused by patent foramen ovale (PFO) is a common etiology of cryptogenic stroke (CS), particularly in young and middle-aged patients. Studies about right-to-left shunt (RLS) detection using contrast-enhanced transcranial Doppler (c-TCD) are numerous. According to the time phase and number of microbubbles detected on c-TCD, RLS can be classified and graded. We hypothesized that the characteristics of an infarction lesion on diffusion-weighted imaging differs when combining the type and grade of RLS on c-TCD in patients with PFO-related CS.

AIM

To explore the characteristics of infarction lesions on diffusion-weighted imaging when combining the RLS type and grade determined by c-TCD.

METHODS

We retrospectively evaluated CS patients from August 2015 to December 2019 at a tertiary hospital. In total, 111 PFO-related CS patients were divided according to whether RLS was permanent (microbubbles detected both at resting state and after the Valsalva maneuver) or latent (microbubbles detected only after the Valsalva maneuver) on c-TCD. Each group was subdivided into small, mild and large RLS according to the grade of shunt on c-TCD. A normal control group was composed of 33 patients who suffered from simple dizziness. Intragroup and intergroup differences were analyzed in terms of clinical, laboratory and diffusion-weighted imaging lesion characteristics. The correlation between RLS grade evaluated by c-TCD and size of PFO determined by transesophageal echocardiography were also analyzed.

RESULTS

In 111 patients with PFO-related CS, 68 had permanent RLS and 43 had latent RLS. Clinical characteristics and laboratory tests were not significantly different among the permanent RLS, latent RLS and normal control groups. The proportion of patients with multiple territory lesions in the permanent RLS group (50%) was larger than that in the latent RLS group (27.91%; P = 0.021). Posterior circulation was more likely to be affected in the latent RLS group than in the permanent RLS group (30.23% vs 8.82%, P = 0.004). Permanent-large and latent-large RLS were both more likely to be related to multiple (P_trend = 0.017 and 0.009, respectively), small (P_trend = 0.035 and 0.006, respectively) and cortical (P_trend = 0.031 and 0.033, respectively) lesions. The grade of RLS evaluated by c-TCD was correlated to the size of PFO determined by transesophageal echocardiography (r = 0.758, P < 0.001).

CONCLUSION

Distribution of the infarct suggested the possible type of RLS. Multiple, small and cortical infarcts suggest large RLS induced by a large PFO.

Factors leading to the risk of stroke mortality: a cross-sectional study with lung cancer patient-based large sample

To identify the risk factors for stroke mortality among lung cancer patients on the basis of the Surveillance, Epidemiology, and End Results (SEER) database. The clinical data of lung cancer patients diagnosed between 2004 and 2016 were collected in the SEER database. The stroke mortality of lung cancer patients was compared with the general population using standardized mortality ratios (SMRs). COX proportional hazard model was applied to analyze the risk factors for stroke mortality among lung cancer patients. Among 82 454 patients, 4821 (5.85%) died of stroke. The stroke mortality rate in lung cancer patients significantly increased compared with the general population [SMR: 1.73, 95% confidential interval (95% CI), 1.69-1.78]. Differences were pronounced between the patients with stroke death and those without regarding all the basic characteristics (P < 0.001). Multivariate COX analysis showed that the risk factors for stroke mortality among lung cancer patients included increasing age, males, the black, grade II-III, distant metastasis and higher American Joint Committee on Cancer (AJCC) TNM stage, whereas adenocarcinoma was found to be a protective factor compared with squamous cell carcinoma. Increasing age, males, the black, grade II-III, distant metastasis and higher TNM stage are associated with an increased risk of stroke mortality among lung cancer patients, but adenocarcinoma with a lowered risk.

Endovascular thrombectomy for acute ischemic stroke in patients with cancer: a propensity-matched analysis

BACKGROUND

There is a paucity of data and a belief that endovascular thrombectomy (EVT) has low efficacy for acute ischemic stroke (AIS) in patients with cancer. We aimed to critically compare the clinical outcomes of EVT for AIS in patients with and without cancer.

METHODS

Records of all patients undergoing EVT for AIS between January 2015 and 2020 were screened for cancer at the time of EVT. Active cancer was defined as patients who were diagnosed with cancer and were undergoing or refused treatment for that cancer. Baseline modified Rankin Scale (mRS), age and sex were used in a 1:5 propensity score matching ratio. After matching we evaluated for any change in the National Institutes of Health Stroke Scale (NIHSS) from baseline to discharge, hemorrhagic transformation (HT), and 90-day mRS and mortality.

RESULTS

There were 19 patients with cancer and 95 matched controls. The mean±SD age was 70.89±11.16 years, and 17 (89.47%) were female. The baseline NIHSS was 22±7.5 and baseline mRS was 1 (IQR 1). There was no significant difference in change in baseline to discharge NIHSS, 90-day mRS or mortality; 90-day mRS 0-2 was 45.2% in the non-cancer group versus 46.7% in cancer group (p=0.54). HT was significantly higher in patients with cancer (57.89% vs 6.49%, p<0.001).

CONCLUSIONS

In propensity matched analysis of patients undergoing EVT for AIS with and without cancer, 90-day functional outcomes and mortality were similar. However, there was a significantly higher rate of HT in cancer patients.

Effects of intracranial atherosclerosis and atrial fibrillation on the prognosis of ischemic stroke with active cancer

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.

Ischemic Stroke Risk Among Adult Brain Tumor Survivors: Evidence to Guide Practice

ABSTRACT

INTRODUCTION: Primary brain tumors are the leading cause of cancer mortality in the United States affecting approximately 90,000 Americans each year. A major complication for brain tumor survivors is acute ischemic stroke (AIS). Currently, there are limited research to provide guidelines for AIS prevention and management in adult brain tumor survivors. The purpose of this review is to discuss the most common risk factors for AIS in adult brain tumor survivors along with best evidence for assessment, screening, and strategies to prevent AIS in this population. METHODS: Relevant literature was identified by searching CINAHL and PubMed databases using the following keywords: "brain tumor survivors," "adults," "stroke," "risk factors," "guidelines," "prevention," and "management". Articles not pertaining to adult brain tumor survivors and AIS were excluded. RESULTS: The location of the tumor, dose, extent, and type of radiation contribute to the development of vascular injury and subsequent carotid stenosis among brain tumor survivors. Endothelial growth factor inhibitor and chemotherapy drugs induces vascular remodeling. Other symptoms such as neurological impairments and co-morbidities are also present among brain tumor survivors. Furthermore, AIS increases from the time of primary brain tumor diagnosis and incidence further increases among patients who were diagnosed with a brain tumor as a child. CONCLUSION: Nurses play a key role in the assessment, prevention, and identifying individuals who are at risk of AIS during brain tumor survivorship. Engaging patients and their caregivers on minimizing their risks of AIS is crucial in the outpatient setting. Annual surveillance visits that include intracranial artery imaging should be used to identify individuals considered most at risk for developing AIS symptoms.

When Should Neuroendovascular Care for Patients With Acute Stroke Be Palliative?

Noncurative surgeries intended to relieve suffering during serious illness or near end of life have been analyzed across palliative settings. Yet sparse guidance is available to inform clinical management decisions about whether, when, and which interventions should be offered when ischemic stroke and other neurological complications occur in patients whose survival is extended by other novel disease-modifying interventions. This case commentary examines key ethical and clinical considerations in palliative neuroendovascular care of patients with acute stroke.

Histopathological analysis of retrieved thrombi from patients with acute ischemic stroke with malignant tumors

BACKGROUND

The procoagulant state in cancer increases the thrombotic risk, and underlying cancer could affect treatment strategies and outcomes in patients with ischemic stroke. However, the histopathological characteristics of retrieved thrombi in patients with cancer have not been well studied. This study aimed to assess the histopathological difference between thrombi in patients with and without cancer.

METHODS

We studied consecutive patients with acute major cerebral artery occlusion who were treated with endovascular therapy between October 2010 and December 2016 in our single-center registry. The retrieved thrombi were histopathologically investigated with hematoxylin and eosin and Masson's trichrome staining. The organization and proportions of erythrocyte and fibrin/platelet components were studied using a lattice composed of 10×10 squares.

RESULTS

Of the 180 patients studied, 17 (8 women, age 76.5±11.5 years) had cancer and 163 (69 women, age 74.1±11.2 years) did not. Those with cancer had a higher proportion of fibrin/platelets (56.6±27.4% vs 40.1±23.9%, p=0.008), a smaller proportion of erythrocytes (42.1±28.3% vs 57.5±25.1%, p=0.019), and higher serum D-dimer levels (5.9±8.2 vs 2.4±4.3 mg/dL, p=0.005) compared with the non-cancer cases. Receiver operating characteristic curve analysis showed the cut-off ratio of fibrin/platelet components related to cancer was 55.7% with a sensitivity of 74.8%, specificity 58.8% and area under the curve (AUC) value of 0.67 (95% CI 0.53 to 0.81), and the cut-off ratio of erythrocyte components was 44.7% with a sensitivity of 71.2%, specificity 58.9% and AUC value of 0.66 (95% CI 0.51 to 0.80).

CONCLUSIONS

Thromboemboli of major cerebral arteries in patients with cancer were mainly composed of fibrin/platelet-rich components.

Thromboembolism, mortality, and bleeding in 2,435,541 atrial fibrillation patients with and without cancer: A nationwide cohort study

BACKGROUND

The number of patients with atrial fibrillation (AF) and cancer is rapidly increasing in clinical practice. The impact of cancer on clinical outcomes in this patient population is unclear, as is the performance of the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol) and CHA₂ DS₂ -VASc (Congestive Heart Failure, Hypertension, Age ≥ 75 years, Diabetes Mellitus, Stroke or Transient Ischemic Attack, Vascular Disease, Age 65 to 74 Years, Sex Category) scores.

METHODS

This was an observational, retrospective cohort study including 2,435,541 adults hospitalized with AF. The authors investigated the incidence rates (IRs) of all-cause and cardiovascular mortality, ischemic stroke, major bleeding, and intracranial hemorrhage (ICH) according to the presence of cancer and cancer types.

RESULTS

Overall, 399,344 (16.4%) had cancer, with the most common cancers being metastatic, prostatic, colorectal, lung, breast, and bladder. During a mean follow-up of 2.0 years, cancer increased all-cause mortality (hazard ratio [HR], 2.00; 95% confidence interval [CI], 1.99-2.01). The IR of ischemic stroke was higher with pancreatic cancer (2.8%/y), uterine cancer (2.6%/y), and breast cancer (2.6%/y), whereas it was lower with liver/lung cancer (1.9%/y) and leukemia/myeloma (2.0%/y), in comparison with noncancer patients (2.4%/y). Cancer increased the risk of major bleeding (HR, 1.27; 95% CI, 1.26-1.28) and ICH (HR, 1.07; 95% CI, 1.05-1.10). Leukemia, liver cancer, myeloma, and metastatic cancers showed the highest IRs for major bleeding/ICH. Major bleeding and ICH rates progressively increased with the HAS-BLED score, which showed generally good predictivity with C indexes > 0.70 for all cancer types. The CHA₂ DS₂ -VASc score's predictivity was slightly lower in AF patients with cancer.

CONCLUSIONS

Cancer increased all-cause mortality, major bleeding, and ICH risk in AF patients. The association between cancer and ischemic stroke differed among cancer types, and in some types, the risk of bleeding seemed to exceed the thromboembolic risk.

[Clinical and Imaging Features of Acute Cerebral Infarction in Non-small Cell Lung Cancer Patients with Trousseau Syndrome]

背景与目的

急性脑梗死是Trousseau综合征（Trousseau syndrome, TS）的一种表现形式，但相对少见，往往容易被临床医师忽视。本研究探讨非小细胞肺癌（non-small cell lung cancer, NSCLC）合并TS以急性脑梗死为表现的临床、实验室检查及影像学特点。

方法

回顾性收集25例以急性脑梗死为表现的NSCLC合并TS患者的临床资料、实验室检查和影像学资料，进行分析总结。

结果

25例患者中男性18例，女性7例，年龄39岁-78岁，其中腺癌22例、鳞癌2例和大细胞癌1例；所有患者均有急性脑梗死的临床症状和体征；血浆D-二聚体明显升高，凝血酶原时间及活化部分凝血活酶时间均有不同程度的缩短；所有患者在头部磁共振成像（magnetic resonance imaging, MRI）[扩散加权成像（diffusion-weighted imaging, DWI）序列]平扫上均表现为累及多个颅内动脉供血区的急性多发性脑梗死灶，头磁共振血管成像（MR angiography, MRA）上梗死灶对应的供血血管管腔未见中重度狭窄。

结论

NSCLC合并急性多发性脑梗死是TS的少见表现类型，其特点是累及多个动脉供血区的急性多发性脑梗死灶伴有明显高凝状态；提高对该病的早期认识可以为临床诊疗提供一定的帮助。

Tumor metastasis has a significant relationship with the development of acute ischemic stroke in Chinese cancer patients: a retrospective study

OBJECTIVE

This study was designed to analyze the relationship between tumor metastasis and acute ischemic stroke (AIS) in Chinese cancer patients.

METHODS

This retrospective study included 119 cancer patients with AIS and 152 cancer patients without AIS. Basic information was collected and tumor metastasis status was determined for all patients.

RESULTS

The whole cohort had a median age of 59 (49-69) years with 150 men (55.4%). There were 98 patients (36.2%) with tumor metastasis. Patients with AIS had significantly more males, tumor metastasis, lung cancer, hypertension, diabetes mellitus, higher age, D-dimer, international normalized ratio, prothrombin time, prothrombin activity, and thrombin time, while they had significantly lower levels of hemoglobin, red blood cells, and hematocrit. In multivariate logistic regression analysis, AIS was significantly and positively associated with age, tumor metastasis, D-dimer, and thrombin time. In multivariate Cox regression analysis, tumor metastasis, AIS, D-dimer, thrombin time, and fibrinogen were significantly and positively associated with worse prognosis.

CONCLUSIONS

This study demonstrates that tumor metastasis was positively and independently associated with AIS in Chinese cancer patients, suggesting that tumor metastasis has a significant relationship with the development of AIS. Additionally, tumor metastasis and AIS had negative independent effects on the prognosis of patients.

Pathophysiology, Mechanism, and Outcome of Ischemic Stroke in Cancer Patients

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.

Case report on 5-fluorouracil induced cerebrovascular accident

Introduction

5-Fluorouracil is an antineoplastic agent generally used to treat various types of solid tumors. The common adverse drug reaction associated with 5-fluorouracil are myelosuppression, mucositis, diarrhea, and hand-foot syndrome. Neurological side effects such as headache, dizziness, convulsion, encephalopathy, and acute cerebellar syndrome are rare in nature.

Case presentation

We report a case of 5-fluorouracil induced cerebrovascular accident (CVA) in a patient with no risk factors for CVA before chemotherapy. A 37 years old female patient diagnosed with carcinoma rectum underwent six cycles of chemotherapy with 5- fluorouracil- calcium leucovorin- irinotecan (FOLFIRI regimen). After completing the last cycle, she developed headache, vomiting, and facial deviation along with high blood pressure (260/160 mmHg). MRI brain was done, and it revealed acute non-hemorrhagic lacunar infarct in the left half of pons. 5-fluorouracil induced CVA was suspected and was managed with dual antiplatelet, statin, and antihypertensives.

Conclusion

The clinicians and clinical pharmacists must be aware about the potential of 5-FU to induce rare side effects such as CVA even in low risk patients in order to avoid permanent harm to the patient

Independent risk factors and the potential predictors of bladder cancer-related ischemic stroke

Objective

To investigate the independent risk factors and potential predictors of bladder cancer-related ischemic stroke (BCRIS).

Methods

This was a multi-center retrospective study including patients with active bladder cancer and acute ischemic stroke without traditional stroke risk factors (BCRIS group), and sex- and age-matched patients with active bladder cancer alone (control group). Data were collected between January 2006 and December 2018. Uni- and multivariate analyses were performed to identify independent risk factors for BCRIS. The predictive performance of these risk factors was assessed using receiver operating characteristic (ROC) curves.

Results

Records were retrospectively reviewed from 60 BCRIS patients and 120 bladder cancer controls. Univariate analysis revealed that serum D-dimer and carcinoembryonic antigen (CEA) levels and the platelet and neutrophil counts were significantly higher in BCRIS patients compared with controls. Multivariate analysis identified the three above-mentioned variables as independent risk factors for BCRIS. The product of all three factors gave the largest area under the ROC curve.

Conclusions

Elevated serum D-dimer and CEA levels and increased platelet count were independent risk factors for BCRIS, and the cut-off value based on the product of the three independent risk factors (≥2,640,745.29) could serve as a potential predictor of BCRIS.

D-dimer and diffusion-weighted imaging pattern as two diagnostic indicators for cancer-related stroke: A case-control study based on the STROBE guidelines

The aim of this study was to evaluate the risk factors and elucidate the clinical characteristics of cancer-associated ischemic stroke to differentiate it from conventional ischemic stroke in China and East Asia. Between June 2012 and June 2016, a retrospective analysis was performed on 609 stroke patients with cancer. They were divided into 3 groups: cancer-stroke group (CSG, 203 cases), stroke group (SG, 203 cases), and cancer group (CG, 203 cases). The D-dimer levels and diffusion-weighted imaging lesion (DWI) pattern were compared to an age- and sex-matched control group. The most common cancer types were colorectal cancer (20.2%) and lung cancer (18.72%). The average D-dimer level in stroke patients and cancer patients were 0.34 and 1.50 mg/L, respectively. The descending levels of D-dimer from cancer types were lung cancer (2.06 mg/L), pancreas (1.74 mg/L), gastric (1.61 mg/L), among others. Univariate analysis of the CSG and the others shows there were significant differences in the prevalence of the levels of D-dimer and DWI pattern, hypertension, diabetes mellitus, and thrombus. CSG has a unique pathological characteristic including high plasma D-dimer levels and multiple vascular lesions. The results show that D-dimer and DWI can be used as diagnostic index in clinical practice.

Clinical Characteristics and Risk Factors of Lung Cancer-Associated Acute Ischemic Stroke

OBJECTIVE

To research the clinical characteristics and risk factors of lung cancer-associated acute ischemic stroke (LCA-AIS).

METHODS

Patients diagnosed with LCA-AIS, simple lung cancer, and simple AIS were enrolled. The primary information, laboratory results, tumor histopathology, neurological deficits, and survival time of the patients were collected and analyzed.

RESULTS

(1) In the LCA-AIS group, the pathology of 69.56% patients were adenocarcinoma, and the proportion of poorly differentiated patients was significantly more than that in moderately differentiated or highly differentiated. The number of stage IV lung cancer patients in the LCA-AIS group was significantly more common than in other stages. (2) 56.52% of patients with lung cancer were diagnosed before AIS, and the peak of AIS attack was 1-6 months after the diagnosis of lung cancer. (3) The independent risk factors of LCA-AIS were CYFRA-211 (OR 1.070; 95% confidence interval 1.005, 1.139; p = 0.035), TT (OR 1.275; 95% confidence interval 1.089, 1.493; p = 0.003), and Hct (OR 0.878; 95% confidence interval 0.779, 0.990; p = 0.034), making ROC curve, suggesting the area under the curve is 0.871. (4) The neurological deficit of patients in the LCA-AIS group was similar to the simple AIS group and could not be identified by the severity of neurological deficits. (5) The median survival time of LCA-AIS group patients was five months (95% confidence interval 3.796, 6.204). There were statistical differences in survival time between LCA-AIS group and simple AIS group patients (p < 0.001).

CONCLUSIONS

The interaction between lung cancer and AIS may shorten patients' life expectancy and worsen their quality of life.

D-dimer and C-reactive Protein as Potential Biomarkers for Diagnosis of Trousseau's Syndrome in Patients with Cerebral Embolism

BACKGROUND

Differentiating stroke due to Trousseau's syndrome from other types of cerebral embolism is challenging, especially in patients with occult cancer. The current study aimed to determine predicting factors and biomarkers of stroke due to Trousseau's syndrome.

METHODS

This retrospective study comprised 496 consecutive patients with acute cerebral embolism, including 19, 85, 310, and, 82 patients with stroke due to Trousseau's syndrome, artery-to-artery embolism, cardioembolic stroke, and embolic stroke with undetermined source, respectively. All patients were evaluated within 72 hours of onset. The clinical characteristics, laboratory findings, and patterns on diffusion-weighted magnetic resonance imaging (DWI) were compared among the groups.

RESULTS

Plasma D-dimer and C-reactive protein (CRP) levels were significantly higher in the Trousseau's syndrome than in the other causes of cerebral embolism. Multivariate analyses demonstrated that female sex, multiple lesions on DWI, high D-dimer and CRP levels, and low platelet and low brain natriuretic peptide levels were independent predictors that could distinguish Trousseau's syndrome from the other causes of cerebral embolism. The cutoff values of D-dimer and CRP to identify stroke due to Trousseau's syndrome was 2.68 µg/mL fibrinogen equivalent units and .29 mg/dL, respectively.

CONCLUSIONS

The elevated D-dimer and CRP levels on admission in addition to specific clinical features may be useful for diagnosis of Trousseau's syndrome in patients with cerebral embolism.

Cancer Exacerbates Ischemic Brain Injury Via Nrp1 (Neuropilin 1)-Mediated Accumulation of Regulatory T Cells Within the Tumor

Background and Purpose- Adoptive transfer of regulatory T cells (Tregs) protect against stroke; however, Treg-based therapy raises concerns in stroke patients with cancer because of the immunosuppressive function of Tregs. The purpose of this study was to investigate the role of Tregs in cerebral ischemic brain injury with concomitant cancer. Methods- To establish a cancer phenotype, MC38 colon cancer or B16 melanoma cells (5×10⁵/mice) were injected subcutaneously into C57BL/6J mice 2 to 3 weeks before distal middle cerebral artery occlusion surgery. Infarct volume, neuroinflammation, and Tregs infiltration were measured by 2,3,5-triphenyltetrazolium chloride staining, immunofluorescence staining, real-time polymerase chain reaction, and flow cytometry. Mechanistically, Nrp1 (neuropilin-1) monoclonal antibody was used to block the Nrp1 effect on Tregs ex vivo before being transferred into recombination activating gene 1 (Rag1-/-) stroke mice, which are devoid of T and B cells, or a Nrp1 neutralization antibody was injected systemically into cancer-bearing wild-type mice after stroke. Results- Cancer-bearing mice with stroke exhibited augmented neuroinflammation and fewer Tregs in the brain, but more infiltration of Tregs to the tumor was apparent after distal middle cerebral artery occlusion. Depletion of Tregs increased infarct volume in stroke mice but did not further exacerbate brain injury in cancer-bearing stroke mice. Nrp1 blocking ex vivo or Nrp1 systemic neutralization attenuated ischemic brain injury and reversed accumulation of Tregs within tumor after stroke in cancer-bearing mice. Conclusions- Nrp1 signaling mediated accumulation of Tregs within tumor might play a critical role in exacerbating ischemic brain injury in cancer-bearing mice and may represent a promising immune modulatory target for the combined condition of cancer and stroke.

The emerging value of serum D-dimer measurement in the work-up and management of ischemic stroke

Background

Elevated D-dimer levels are a marker of both thrombin formation and fibrinolysis. Currently D-dimer measurement is routinely used for ruling out venous thromboembolism and diagnosis/monitoring of disseminated intravascular coagulation. Recent emerging data suggest that D-dimer may become an important biomarker in ischemic stroke as well as in cardiovascular diseases.

Aims

To outline the clinical utility of D-dimer in work-up and management of ischemic stroke.

Summary

D-dimer measurement is most useful in stroke with active cancer as it can confirm etiologic diagnosis, predict recurrent stroke risk, and aid treatment decision in cancer-associated stroke. In cryptogenic stroke, high D-dimer levels can also provide clues for the cause of stroke as occult cancer and undetected cardiac embolic source as occult atrial fibrillation and may be helpful in treatment decision making of secondary stroke prevention. Serial D-dimer measurements should be further studied to monitor antithrombotic therapy effectiveness in both cardiogenic and cryptogenic etiologies.

Conclusion

Accumulating data suggests the utility of D-dimer test in the management of ischemic stroke, although the evidence is still limited. Future studies would clarify the role of D-dimer measurement in ischemic stroke.

Stroke in malignancy: complexities of diagnosis and management: a case report

BACKGROUND

Although there is an established association between cancer and stroke, the role of malignancy as a causative agent or comorbidity is not always clear. Moreover, there are no established guidelines on the acute treatment of cancer-associated stroke or optimal anticoagulation. This case report illustrates the significance of these practice gaps.

CASE PRESENTATION

A 62-year-old Caucasian woman presented to our institute with acute neurological deficits and was found to have an occluded left middle cerebral artery on a computed tomographic angiogram. She was administered intravenous alteplase and underwent unsuccessful endovascular clot retrieval. Besides smoking and her age, she had no cerebrovascular risk factors, and the results of baseline investigations for the cause of stroke were negative. Subsequent computed tomography of the chest, abdomen, and pelvis showed metastatic malignancy, and in the context of a significantly elevated serum cancer antigen 19-9, we suspected a pancreatic primary cancer. A transthoracic echocardiogram demonstrated mitral regurgitation but no visible vegetation. The patient died of her illness. We made a diagnosis of cancer-associated stroke, specifically a likely case of nonbacterial thrombotic endocarditis.

CONCLUSIONS

This case highlights the importance of having a high threshold of suspicion for malignancy as a cause of stroke.

Predicting outcomes in patients with cancer and atrial fibrillation

Background:

The role of cancer-specific factors for ischemic stroke and mortality in patients with cancer and atrial fibrillation (AF) is unknown. We evaluated the utility of a previously validated risk tool for venous thromboembolism (VTE) in cancer outpatients [Khorana score (KS)] in predicting stroke and mortality in cancer patients with AF.

Methods:

We conducted a retrospective cohort study of patients with cancer and AF at the Cleveland Clinic from 2008 to 2014. Outcomes, CHADS2, CHA2DS2-VASc, and KS scores were calculated from date of cancer diagnosis. Prognostic factors were identified with Fine and Gray regression (for stroke) or Cox proportional hazards analysis (for mortality).

Results:

The study population comprised 1181 patients. Genitourinary (19%), lung (18%), and gastrointestinal (13%) were the most frequent cancers. Overall, 67% had CHADS2 ⩾ 2, 57% had an intermediate KS (1–2), and 7% high KS (⩾3). Median follow up was 26.5 months (range 0.03–76). At a median of 8.2 months (range 0–61), 45 patients (3.8%) developed a stroke and 418 (35%) died. In multivariable analysis a high KS (HR 4.5, 95% CI 3.2–6.3, p < 0.001) was associated with a quadruple risk of death and every point increase in CHADS2 score had a 20% increased risk of death (HR 1.19, 95% CI 1.1–1.2, p < 0.001). The addition of KS did not improve risk stratification for ischemic stroke to CHADS2.

Conclusion:

In patients with cancer and AF, CHADS2 and CHA2DS2-VASc but not KS were predictive of ischemic stroke. A high KS represented a unique predictor of mortality beyond traditional risk scores.

Specific Biomarkers of Prostate Cancer-Associated Ischemic Stroke: A Case-Control Study

Background

Ischemic stroke in cancer patients is associated with poor prognosis. However, the specific biomarkers of cancer-associated ischemic stroke (CaIS) have not been well defined.

Material/Methods

A retrospective study was conducted on PCaIS patients. Clinical data and laboratory and imaging findings were collected. Multivariable logistic regression analysis was used to analyze the independent risk factors for PCaIS. A multiple model combining the independent risk factors of PCaIS was developed using the receiver operating characteristic (ROC) and area under the ROC curve (AUC).

Results

A total of 83 PCaIS patients and 83 prostate cancer (PCa) patients were included. PCaIS patients had higher levels of D-dimer, neutrophil-to-lymphocyte ratio (NLR), and total prostate-specific antigen (T-PSA). In the multivariate analysis, D-dimer [OR=1.001, 95% CI: 1.00,1.00, P=0.002], NLR [OR=1.12, 95% CI: 1.04,1.22, P=0.005], and T-PSA [OR=6.275, 95% CI: 2.57,15.31, P<0.001] were independent risk factors of PCaIS. Additionally, the AUC of the multiple model of PCaIS was 0.815 (95% CI, 0.750–0.869), with sensitivity of 81.71% and specificity of 70.21%.

Conclusions

Elevated levels of D-dimer and T-PSA and increased NLR are independent risk factors of PCaIS. The multiple model of PCaIS can be a specific biomarker and is a reliable predictor of development of PCaIS.

Neurophysiological evidence of impaired attention and working memory in untreated hematologic cancer patients

OBJECTIVE

Neuroimaging studies of hematologic cancer patients report altered activity in dorsal attention and central executive networks. To determine the consequences of these altered brain networks, we evaluated neurophysiological correlates of attention and working memory in hematologic cancer patients prior to initiating treatment.

METHODS

Hematologic cancer patients (19-80 years) were excluded for premorbid cognitive impairment, prior non-hematologic cancer diagnosis, and prior chemotherapy. Attention was manipulated by presenting an irrelevant spatial cue prior to visual search displays. Working memory was manipulated by presenting irrelevant distractors within memory displays. Electroencephalogram was recorded during task performance.

RESULTS

Patients (n = 28) and controls (n = 15) were balanced on age, gender, and education. Spatial cues evoked larger N2pc amplitudes, a correlate of spatial attention, in patients than controls (p < .05; Cohen's d > 0.7). Memory distractors evoked larger contralateral delay activity amplitudes, a correlate of working memory load, in patients (p = .028; Cohen's d = 1.1) but not controls (p = .64).

CONCLUSIONS

Prior to initiating treatment, hematologic cancer patients demonstrated poor control over spatial attention and working memory, consistent with altered dorsal attention and central executive network activity.

SIGNIFICANCE

Hematologic cancer patients may be at a higher risk for selecting, processing, and storing distracting information that would compete with more immediate goal-related behaviors.

Clinical Manifestations and Mechanisms of Autoimmune Disease-Related Multiple Cerebral Infarcts

It is important to investigate the clinical characteristics and identify the stroke mechanisms of patients with autoimmune disease-related stroke, which are necessary for early etiology diagnosis, accurate treatment and preventive strategies. In this article we retrospectively studied eight cases of acute ischemic stroke associated with autoimmune diseases, and without competing conventional stroke etiologies. The characteristics of stroke (clinical and radiological features), the laboratory tests especially serum D-dimer levels (as a marker of hypercoagulable state), and embolic signals on transcranial Doppler were evaluated for all eight patients. High-resolution magnetic resonance imaging (HRMRI), which can help to evaluate vasculitis was performed in four patients. The possible underlying mechanisms of these cases were discussed based on these manifestations. As a result, autoimmune diseases in our study included systemic lupus erythematosus (n=5), mixed connective tissue disease (n=1), central nervous system vasculitis (n=1), and Takayasu arteritis (n=1). All eight patients presented with acute infarction lesions in ≥2 vascular territories. Most patients presented with numerous small and medium infarction lesions located in the cortical and subcortical areas. Multiple stroke mechanisms were involved in these cases, including hypercoagulability (n=4), cardiac embolism (n=1) and vasculitis (n=3). Embolic signals could be detected on transcranial Doppler in all three stroke mechanisms. In conclusion, our study revealed the characteristics of autoimmune disease-related stroke. For patients with multiple acute cerebral infarcts within non-single arterial territories, autoimmune disease is an important etiology not to be neglected. Multiple stroke mechanisms were involved in these cases.

Percutaneous coronary intervention in patients hospitalized for non-ST-elevation myocardial infarction and the risk of postdischarge ischemic stroke at 6-month, 1-year, and 3-year follow-ups

Percutaneous coronary intervention (PCI) is suggested for treating patients with non-ST-elevation myocardial infarction (NSTEMI) to reduce adverse cardiovascular events. However, the short- and long-term effects of PCI on the risk of postdischarge ischemic stroke (IS) in patients hospitalized for NSTEMI remain unclear. This study investigated the association of PCI on the risk of postdischarge IS in patients hospitalized for NSTEMI at different period follow-ups. A population-based cohort study was conducted using data from Taiwan's National Health Insurance Research Database. Propensity score matching (PSM) was used to select 6079 pairs of the patients with NSTEMI treated invasively by PCI (received PCI during hospitalization) and initial conservative strategy (did not receive PCI during hospitalization) with similar baseline characteristics for evaluation. After adjustment for patients' clinical variables and the duration of dual antiplatelet therapy, PCI was associated with a decreased risk of postdischarge IS at 6-month, 1-year, and 3-year follow-ups [adjusted hazard ratio (aHR) = 0.41, 95% confidence interval (CI) = 0.26-0.67, p < 0.001; aHR = 0.61, 95% CI 0.43-0.86, p = 0.004; and aHR = 0.69, 95% CI 0.54-0.89, p = 0.005respectively]. In the patients who had a CHA₂DS₂-VASc score of ≥2, PCI was also associated with a decreased risk of postdischarge IS at 6-month, 1-year, and 3-year follow-ups (aHR = 0.54, 95% CI 0.36-0.83, p = 0.005; aHR = 0.72, 95% CI 0.52-1.00, p = 0.048; and aHR =0.73, 95% CI 0.58-0.91, p = 0.005, respectively). These findings suggested that PCI might reduce the risk of postdischarge IS in patients hospitalized for NSTEMI.

The Long-Term Effect of Cancer on Incident Stroke: A Nationwide Population-Based Cohort Study in Korea

Background and Purpose: Despite the recent growing interest in the cancer–stroke association, the long-term effect, and organ-specific association with stroke incidence in subjects with cancer have not been clearly defined.

Methods: Data were obtained from the Korean National Health Insurance Service National Sample Cohort database between 2002 and 2015. To investigate the effects of cancer on stroke incidence, subjects were classified into cancer and non-cancer groups based on the period after cancer diagnosis and origin organ of cancer. To minimize the effects of selection bias, we performed a propensity score matching analysis with covariates of demographic data, vascular risk factors, antithrombotics use and statin use. Incident stroke was diagnosed based on operational definition and classified into ischemic stroke and hemorrhagic stroke.

Results: Data of 20,707 subjects with cancer and 675,594 without cancer were analyzed for 7 follow-up years. The subjects with cancer had higher risk of any stroke (subdistribution hazard ratio [SHR], 1.13; 95% confidence interval [CI], 1.02–1.26; p = 0.0181) than those without cancer. Similar trend was found for ischemic stroke (SHR, 1.17; 95% CI, 1.05–1.31; p = 0.0054), but not for hemorrhagic stroke. The risk of stroke was increased in subjects with cancer in the digestive organ, respiratory and intrathoracic organ, and “others (such as breast and female and male reproductive organs)” in 3 years; however, the association disappeared thereafter except those with “others” cancer. Chemotherapy increased the risk of ischemic stroke (SHR 1.21; 95% CI, 1.03–1.41).

Conclusions: Cancer increases the risk of stroke at 3 years after the diagnosis of cancer, and the effect was maintained for 7 years. The association between cancer and stroke incidence depends on the organ from which the cancer originated and chemotherapy.

Neurologic manifestations of elderly patients with cancer

BACKGROUND

The incidence of cancer is an age-related phenomenon; therefore, the interest on clinical manifestations, diagnostic approach and treatment strategies for older patients diagnosed with cancer has increased lately. Neurologic symptoms are one of the main reasons for consultation and a common cause of decreased quality of life among cancer patients.

AIMS

To identify the neurologic manifestations of patients ≥ 65 years of age diagnosed with cancer and compare them to those presented by a younger population.

METHODS

Cross-sectional study of cancer patients referred to neuro-oncologic consultation at a Cancer Center. Sociodemographic, health and oncologic characteristics were obtained through clinical interviews. Clinical symptoms and final diagnoses were also recorded. Bivariate logistic regression analyses were carried out.

RESULTS

More than 17,000 neuro-oncologic consultations in 3015 patients were given, 27% (n = 811) of them were ≥ 65 years of age. Most frequent primary neoplasms in elderly patients were: breast cancer, hematologic neoplasms, gynecological, urologic, skin and head and neck cancers. Elderly patients had an increased risk of having the following diagnoses: abnormal movements, stroke, peripheral vertigo, dementia, degenerative spine disorder, and delirium.

DISCUSSION

Elderly patients are considered a vulnerable population. The present study found that the main neoplasms associated with neurological manifestations are similar to the reported previously. We described the main symptoms that led to a neuro-oncological assessment. Moreover, we enlisted the final diagnoses made on elderly patients and compared them with others reports. To the best of our knowledge, this study provides valuable information, since there is scarce evidence in the literature about this topic.

CONCLUSION

Identifying the frequency and correlation of neurologic manifestations in older cancer patients will allow for the implementation of timely multidisciplinary care in an attempt to improve these patients' health-related quality of life.

Clinical presentation, risk factors and outcome of central nervous system metastasis vs stroke in cancer patients

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.

Biomarkers and potential pathogenesis of colorectal cancer-related ischemic stroke

AIM

To investigate the specific biomarkers and potential pathogenesis of colorectal cancer-related ischemic stroke (CRCIS).

METHODS

A retrospective study was conducted on CRCIS patients (colorectal cancer patients with ischemic stroke without conventional stroke risk factors) registered at seven centers between January 2007 and December 2017. Clinical data and laboratory and imaging findings were compared with age- and sex- matched patients with colorectal cancer (CRC) without ischemic stroke that were admitted to the same hospital during the same period. Univariate and multivariate analyses were performed to analyze the independent risk factors for CRCIS. A receiver operator characteristic curve was configured to calculate the optimal cut-off value of the products of the independent risk factors for CRCIS.

RESULTS

A total of 114 CRCIS patients and 114 CRC patients were included. Multiple lesions in multiple vascular territories were common in CRCIS patients (71, 62.28%). The levels of plasma D-dimer, carcinoembryonic antigen (CEA), cancer antigen 125, and neutrophil count were significantly higher in CRCIS patients than in CRC patients. Multiple logistic regression analysis revealed that plasma D-dimer levels [odds ratio (OR) = 1.002, 95% confidence interval (CI): 1.001-1.003, P < 0.001], CEA levels (OR = 1.011, 95%CI: 1.006-1.015, P < 0.001), and neutrophil count levels (OR = 1.626, 95%CI: 1.268-2.087, P < 0.001) were independent risk factors for CRCIS. In addition, receiver operator characteristic curve revealed that the area under curve for the products of plasma D-dimer, CEA, and neutrophil count was 0.889 ± 0.022 (95%CI: 0.847-0.932, P < 0.001), and the optimal cut-off value for the product was 252.06, which was called the CRCIS Index, with a sensitivity of 86.0% and specificity of 79.8%.

CONCLUSION

Hypercoagulability induced by elevated CEA and neutrophils may be an important cause of CRCIS. The CRCIS index, which serves as a biomarker of CRCIS, needs further study.

Subcutaneous Heparin Therapy for Patients with Cancer-Associated Stroke

BACKGROUND

Anticoagulation therapy, particularly subcutaneous heparin therapy, is recommended for cancer-associated thrombosis. However, not starting or discontinuing anticoagulation was not rare. The aim of the present study was to examine the practical issues related to anticoagulation therapy and effects of subcutaneous heparin therapy for cancer-associated stroke.

METHODS

Patients with cancer-associated stroke in our stroke center between October 2014 and August 2017 who were diagnosed as having acute ischemic stroke based on diffusion-weighted imaging were retrospectively enrolled. Baseline clinical characteristics, heparin injection, reasons for no subcutaneous heparin therapy, and clinical outcomes were collected.

RESULTS

A total of 59 patients with cancer-associated stroke (75 ± 10 years old, male 42%) were enrolled. Lung cancer was the most frequently observed cancer (n = 17, 29%), followed by gastric cancer (n = 8, 14%) and pancreatic cancer (n = 8, 14%). Of the 19 patients (32%) who underwent subcutaneous heparin therapy, it was discontinued in 9 (47%), mainly because of patients' medical conditions (deterioration of cancer or hemorrhagic complication). Ten patients with long-term subcutaneous heparin therapy did not have stroke recurrence. In contrast, among nine patients who discontinued subcutaneous heparin therapy, three (33%) had recurrence of ischemic stroke. Of the 40 patients without subcutaneous heparin therapy, the main reasons for no subcutaneous heparin therapy were the patients' medical conditions (n = 22, 55%).

CONCLUSIONS

Although subcutaneous heparin therapy was given to only one third of cancer-associated stroke patients, long-term subcutaneous heparin therapy might prevent recurrence of cancer-associated stroke.

Platelet count is associated with outcome in cancer patients with stroke

INTRODUCTION

Cerebrovascular disease (CVD) and cancer are among the most common causes of mortality worldwide, preceded only by ischemic heart disease (IHD). Thrombocytopenia was shown to be associated with poor outcomes in IHD and CVD in the general population. This study aimed to assess the relationship of thrombocytopenia with poor outcomes in cancer patients with CVD.

MATERIALS AND METHODS

Data on patients with concomitant CVD and cancer who were initially treated at a cancer referral center between January 2010 and December 2017 were included. Thrombocytopenia was defined as a platelet count < 150,000/mm³ during the first 24 h of CVD symptom onset. The IRB (CI/837/17) approved the review of clinical records.

RESULTS

Among 268 cancer patients with CVD included in the study, 210 met the inclusion criteria. Median overall survival of the entire cohort was 7.2 months, which was significantly shorter in males (p = 0.029) and patients with hematologic tumors (p = 0.009), hemorrhagic CVD (p < 0.001), altered mental status (p < 0.001), and thrombocytopenia (p < 0.001). Multiple regression logistic analysis revealed that thrombocytopenia (risk ratio [RR] 1.6, 95% confidence interval [CI] 1.1-2.4) and altered mental status (RR 2.7, 95% CI 1.9-4.0) remained statistically significant risk factors for mortality.

CONCLUSION

In cancer patients with CVD, thrombocytopenia at the time of CVD diagnosis and altered mental status during initial clinical evaluation were associated with higher mortality, which should be confirmed in future studies.

Ischemic stroke in cancer patients: A review of an underappreciated pathology

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.

Risk Factors, Biomarkers, Etiology, Outcome and Prognosis of Ischemic Stroke in Cancer Patients

Introduction: Cerebrovascular disease is the second most common complication in individuals with tumours. The aim of this study was to investigate risk factors, biomarkers, etiology and prognosis of ischemic stroke in cancer patients (ISCPs). Methods: The medical records of 619 consecutive patients who were admitted with acute ischemic stroke from January 2012 to November 2014 were retrospectively evaluated. The patients were divided into two groups (group 1, patients with an active cancer prior to the onset of ischemic stroke; group 2, patients without an active cancer history). The demographic data, risk factors, NIHSS scores, thrombocyte count, D-dimer, fibrinogen and C reactive protein (CRP) level at admission, modified Rankin Scale (mRS) scores in the follow-up period and location of lesions on DWI were recorded. The Mann-Whitney U test, chi-squared test and logistic regression was used for analyzing data, p<0.05 being considered statistically significant. Results: A total of 46 (7.4%) ISCPs were included. Hyperlipidemia was significantly lower in the ISCP group (p=0.001). Elevated thrombocyte counts, D-dimer, fibrinogen and CRP levels at admission, acute multiple ischemic lesions, other causes, mortality in hospital and worse outcome were significantly related to ISCP (p<0.05). On logistic regression analysis, follow up mRS>3, acute multiple ischemic lesions located in more than one vascular territory (AMIMCT) and other causes were significantly associated with ISCP (p<0.001). Conclusion: In our study, other causes, AMIMCT and mRS>3 were more common in the ISCP group. We consider that CCS could be more suitable for detecting other causes than TOAST. Biomarkers could be important in the ISCP group.

Temporal changes in the neutrophil to lymphocyte ratio and the neurological progression in cryptogenic stroke with active cancer

Background

Ischemic stroke patients with active cancer frequently experience early neurological deterioration (END); however, the predictors of END are not well studied. The neutrophil to lymphocyte ratio (NLR) has recently been described as a predictor of poor outcomes in cancer and stroke. However, its role in cancer-related stroke has not been addressed.

Aim

We aimed to evaluate the association between the NLR and END in cancer-related stroke patients.

Methods

We included 85 cryptogenic stroke patients with active cancer. END was defined as an increase ≥ 4 on the total National Institutes of Health Stroke Scale (NIHSS) score within 72 hours of admission. The NLR was calculated as the ratio of the absolute neutrophil count to the absolute lymphocyte count. We obtained the NLR during the following three periods: at admission, 1–3 days after admission (D 1–3 NLR) and 4–7 days after admission (D 4–7 NLR).

Results

END occurred in 15 (18%) of the 85 patients. END was significantly associated with the initial NIHSS score, infarction volume, and the D 1–3 NLR. In multivariate analysis, a higher D 1–3 NLR, measured before END events, remained an independent predictor of END [adjusted odds ratio = 2.78, 95% confidence interval = 1.09–7.08, P = 0.032]. In terms of temporal changes in the NLR, the END group showed a tendency toward temporal increase in the NLR at D 1–3 (P = 0.061) with subsequent decrements in the D 4–7 NLR (P = 0.088), while the non-END group showed no significant changes in the NLR between periods.

Conclusions

This study demonstrated that a higher NLR could predict END events in cryptogenic stroke patients with active cancer. However, the results should be confirmed in further large prospective studies.