1
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Kawano T, Mackman N. Cancer patients and ischemic stroke. Thromb Res 2024; 237:155-162. [PMID: 38603819 DOI: 10.1016/j.thromres.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/26/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024]
Abstract
Patients with cancer have an increased risk of ischemic stroke compared to the general population. Additionally, these patients have a worse prognosis compared to stroke patients without cancer. Activation of coagulation appears to play a key role in the pathophysiology of ischemic stroke in patients with cancer. However, the underlying mechanisms remain unknown. Moreover, we do not have a way to identify cancer patients with a high risk of stroke and cannot develop prevention strategies. Therefore, there is an urgent need for neurologists and oncologists to develop screening and prevention strategies for stroke in patients with cancer. In this review, we summarize the characteristics of cancer patients at a high risk of stroke, the predictors for the development of stroke and survival in cancer patients, and possible treatments.
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Affiliation(s)
- Tomohiro Kawano
- Department of Neurology, Kano general hospital, Osaka, Japan
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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2
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Heo JH, Yun J, Kim KH, Jung JW, Yoo J, Kim YD, Nam HS. Cancer-Associated Stroke: Thrombosis Mechanism, Diagnosis, Outcome, and Therapeutic Strategies. J Stroke 2024; 26:164-178. [PMID: 38836266 PMCID: PMC11164583 DOI: 10.5853/jos.2023.03279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 06/06/2024] Open
Abstract
Cancer can induce hypercoagulability, which may lead to stroke. This occurs when tumor cells activate platelets as part of their growth and metastasis. Tumor cells activate platelets by generating thrombin and expressing tissue factor, resulting in tumor cell-induced platelet aggregation. Histopathological studies of thrombi obtained during endovascular thrombectomy in patients with acute stroke and active cancer have shown a high proportion of platelets and thrombin. This underscores the crucial roles of platelets and thrombin in cancer-associated thrombosis. Cancer-associated stroke typically occurs in patients with active cancer and is characterized by distinctive features. These features include multiple infarctions across multiple vascular territories, markedly elevated blood D-dimer levels, and metastasis. The presence of cardiac vegetations on echocardiography is a robust indicator of cancer-associated stroke. Suspicion of cancer-associated stroke during endovascular thrombectomy arises when white thrombi are detected, particularly in patients with active cancer. Cancer-associated stroke is almost certain when histopathological examination of thrombi shows a very high platelet and a very low erythrocyte composition. Patients with cancer-associated stroke have high risks of mortality and recurrent stroke. However, limited data are available on the optimal treatment regimen for stroke prevention in these patients. Thrombosis mechanism in cancer is well understood, and distinct therapeutic targets involving thrombin and platelets have been identified. Therefore, direct thrombin inhibitors and/or antiplatelet agents may effectively prevent stroke recurrence. Additionally, this strategy has potential benefits in cancer treatment as accumulating evidence suggests that aspirin use reduces cancer progression, metastasis, and cancer-related mortality. However, clinical trials are necessary to assess the efficacy of this strategy involving the use of direct thrombin inhibitors and/or antiplatelet therapies.
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Affiliation(s)
- Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, Korea
| | - Jaeseob Yun
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang Hyun Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Wook Jung
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Joonsang Yoo
- Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, Korea
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3
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Costamagna G, Navi BB, Beyeler M, Hottinger AF, Alberio L, Michel P. Ischemic Stroke in Cancer: Mechanisms, Biomarkers, and Implications for Treatment. Semin Thromb Hemost 2024; 50:342-359. [PMID: 37506734 DOI: 10.1055/s-0043-1771270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Ischemic stroke is an important cause of morbidity and mortality in cancer patients. The underlying mechanisms linking cancer and stroke are not completely understood. Long-standing and more recent evidence suggests that cancer-associated prothrombotic states, along with treatment-related vascular toxicity, such as with chemotherapy and immunotherapy, contribute to an increased risk of ischemic stroke in cancer patients. Novel biomarkers, including coagulation, platelet and endothelial markers, cell-free DNA, and extracellular vesicles are being investigated for their potential to improve risk stratification and patient selection for clinical trials and to help guide personalized antithrombotic strategies. Treatment of cancer-related stroke poses unique challenges, including the need to balance the risk of recurrent stroke and other thromboembolic events with that of bleeding associated with antithrombotic therapy. In addition, how and when to restart cancer treatment after stroke remains unclear. In this review, we summarize current knowledge on the mechanisms underlying ischemic stroke in cancer, propose an etiological classification system unique to cancer-related stroke to help guide patient characterization, provide an overview of promising biomarkers and their clinical utility, and discuss the current state of evidence-based management strategies for cancer-related stroke. Ultimately, a personalized approach to stroke prevention and treatment is required in cancer patients, considering both the underlying cancer biology and the individual patient's risk profile.
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Affiliation(s)
- Gianluca Costamagna
- Stroke Unit, Neurology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas F Hottinger
- Services of Neurology and Oncology, Lundin Family Brain Tumor Research Center, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Hematology Central Laboratory, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Stroke Center, Neurology Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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4
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Yoo J, Kwon I, Kim S, Kim HM, Kim YD, Nam HS, Heo JH. Coagulation Factor Expression and Composition of Arterial Thrombi in Cancer-Associated Stroke. Stroke 2023; 54:2981-2989. [PMID: 37886852 DOI: 10.1161/strokeaha.123.044910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/29/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Cancer is associated with an increased risk of stroke. Tumor cells activate platelets, induce a coagulation cascade, and generate thrombin. The composition of thrombi may reflect the mechanism of thrombosis, aiding the determination of the treatment strategy. Here, we investigated the composition and expression of coagulation factors in the thrombi of patients with cancer-associated stroke. METHODS Patients with stroke who underwent endovascular thrombectomy between September 2014 and June 2020 and whose cerebral thrombi were obtained were divided into those with cancer-associated stroke (cancer group) and propensity score-matched patients without cancer (control group), using 1:1 matching based on age and sex. Immunohistochemistry was performed of the thrombi, and the composition and expression of coagulation factors were compared between groups. RESULTS Among the 320 patients who underwent endovascular thrombectomy and who had thrombi obtained, this study included 23 patients with cancer and 23 matched controls. In both groups, the median age was 65 years, and 12 patients (52.2%) were men. Platelet composition was significantly higher in the cancer group than in the control group (median [interquartile range], 51.3% [28.0%-61.4%] versus 9.5% [4.8%-14.0%]; P<0.001). Among coagulation factors, thrombin (26.2% [16.2%-52.7%] versus 4.5% [1.3%-7.2%]; P<0.001) and tissue factors (0.60% [0.34%-2.06%] versus 0.37% [0.22%-0.60%]; P=0.024) were higher and factor X was lower (1.25% [0.39%-3.60%] versus 2.33% [1.67%-4.48%]; P=0.034) in the cancer group. There was a positive correlation between thrombin and platelets in the cancer group (r=0.666; P=0.001) but not in the control group (r=-0.167; P=0.627). CONCLUSIONS Cerebral thrombi in patients with cancer-associated stroke showed higher proportions of platelets, thrombin, and tissue factors, suggesting their key roles in arterial thrombosis in cancer and providing a therapeutic perspective for preventing stroke in patients with cancer-associated stroke.
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Affiliation(s)
- Joonsang Yoo
- Department of Neurology, Yongin Severance Hospital (J.Y.), Yonsei University College of Medicine, Korea
| | - Il Kwon
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea (I.K., S.K., Y.D.K., H.S.N., J.H.H.)
| | - Sungeun Kim
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea (I.K., S.K., Y.D.K., H.S.N., J.H.H.)
| | - Hye Min Kim
- Department of Pathology, Yongin Severance Hospital (H.M.K.), Yonsei University College of Medicine, Korea
| | - Young Dae Kim
- Department of Neurology, Severance Hospital (Y.D.K., H.S.N., J.H.H.), Yonsei University College of Medicine, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea (I.K., S.K., Y.D.K., H.S.N., J.H.H.)
| | - Hyo Suk Nam
- Department of Neurology, Severance Hospital (Y.D.K., H.S.N., J.H.H.), Yonsei University College of Medicine, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea (I.K., S.K., Y.D.K., H.S.N., J.H.H.)
| | - Ji Hoe Heo
- Department of Neurology, Severance Hospital (Y.D.K., H.S.N., J.H.H.), Yonsei University College of Medicine, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea (I.K., S.K., Y.D.K., H.S.N., J.H.H.)
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5
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Gabelmann V, Grabs F, Diestelmeier S, Heindl F, Vosseler M, Münzel T, Sagoschen I, Wild J. Quadrivalvular nonbacterial thrombotic endocarditis in a patient with clear cell cervical cancer. Clin Case Rep 2022; 10:e6434. [PMID: 36267820 PMCID: PMC9576968 DOI: 10.1002/ccr3.6434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 07/14/2022] [Accepted: 09/26/2022] [Indexed: 11/11/2022] Open
Abstract
Nonbacterial thrombotic endocarditis (NBTE) is a rare finding, which is mostly associated with malignant diseases leading to hypercoagulability. We report the case of a severe quadruple valve nonbacterial thrombotic endocarditis in a patient with clear cell cervical cancer.
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Affiliation(s)
- Valentin Gabelmann
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany
| | - Felix Grabs
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany
| | - Simon Diestelmeier
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany
| | - Felix Heindl
- Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen‐EMN (CCC ER‐EMN)University Hospital ErlangenErlangenGermany
| | - Markus Vosseler
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany
| | - Thomas Münzel
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany,German Center for Cardiovascular Research (DZHK)Partner site RheinMainMainzGermany
| | - Ingo Sagoschen
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany
| | - Johannes Wild
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany,German Center for Cardiovascular Research (DZHK)Partner site RheinMainMainzGermany,Center for Thrombosis and Hemostasis (CTH)Johannes Gutenberg‐University MainzMainzGermany
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6
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Baik M, Shim CY, Gwak SY, Kim YD, Nam HS, Lee HS, Nam CM, Heo JH. Patent foramen ovale and risks of recurrence in stroke of determined etiology. Ann Neurol 2022; 92:596-606. [PMID: 35753038 DOI: 10.1002/ana.26449] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 06/20/2022] [Accepted: 06/23/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Patent foramen ovale (PFO) is often found in stroke patients with determined etiologies. PFO may be the actual cause of stroke in some of them. We determined whether the risk of recurrent ischemic stroke differs with PFO status in stroke patients with determined etiologies. METHODS This study included consecutive patients with stroke of determined etiology who underwent transesophageal echocardiography. We compared the rates of recurrent cerebral infarction in patients with versus without PFO, and according to PFO-Associated Stroke Causal Likelihood (PASCAL) classification. RESULTS Of 2314 included patients, 827 (35.7%) had PFO. During a median follow-up of 4.4 years, cerebral infarction recurred in 202 (8.7%). In multivariate modified Cox regression analyses, recurrence of infarction did not significantly differ between patients with PFO and those without PFO (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.64-1.17; P = 0.339). Interaction analysis showed a significant effect of PFO in patients < 65 years (adjusted P for interaction = 0.090). PFO was independently associated with a decreased risk of recurrent infarction in patients younger than 65 years (HR, 0.41; 95% CI, 0.20-0.85; adjusted P = 0.016). Patients with probable PFO-associated stroke on the PASCAL classification had a significantly lower risk of recurrent infarction than those without PFO (HR 0.31; 95% CI 0.10-0.97; P=0.044). INTERPRETATION Considering the generally low risk of recurrence in PFO-associated stroke, PFO may be the actual cause of stroke in some patients with determined etiologies, especially younger patients or those with PFO features of probable PFO-associated stroke. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Minyoul Baik
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si, Gyeonggi-do, South Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Seo-Yeon Gwak
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Department of Research Affairs, Yonsei University College of Medicine, Seoul, South Korea
| | - Chung Mo Nam
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea
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7
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Sun YE, Na HK, Kwak S, Kim YD, Nam HS, Heo JH. Different Thrombus Histology in a Cancer Patient with Deep Vein Thrombosis and Recurrent Strokes. J Stroke 2022; 24:300-302. [PMID: 35677986 PMCID: PMC9194546 DOI: 10.5853/jos.2021.04140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/03/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ye Eun Sun
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Han Kyu Na
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Soomin Kwak
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
- Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Korea
- Correspondence: Ji Hoe Heo Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-1605 Fax: +82-2-393-0705 E-mail:
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8
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Kim H, Kim JT, Lee JS, Kim BJ, Kang J, Lee KJ, Park JM, Kang K, Lee SJ, Kim JG, Cha JK, Kim DH, Park TH, Lee KB, Lee J, Hong KS, Cho YJ, Park HK, Lee BC, Yu KH, Oh MS, Kim DE, Ryu WS, Choi JC, Kwon JH, Kim WJ, Shin DI, Yum KS, Sohn SI, Hong JH, Lee SH, Park MS, Choi KH, Lee J, Bae HJ. Stroke of Other Determined Etiology: Results From the Nationwide Multicenter Stroke Registry. Stroke 2022; 53:2597-2606. [DOI: 10.1161/strokeaha.121.037582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
Stroke of other determined etiology (OE) includes patients with an uncommon cause of stroke. We described the general characteristics, management, and outcomes of stroke in OE and its subgroups.
METHODS:
This study is a retrospective analysis of a prospective, multicenter, nationwide registry, the Clinical Research Center for Stroke-Korea-National Institutes of Health registry. We classified OE strokes into 10 subgroups according to the literature and their properties. Each OE subgroup was compared according to clinical characteristics, sex, age strata, lesion locations, and management. Moreover, 1-year composites of stroke and all-cause mortality were investigated according to the OE subgroups.
RESULTS:
In total, 2119 patients with ischemic stroke with OE types (mean age, 55.6±16.2 years; male, 58%) were analyzed. In the Clinical Research Center for Stroke-Korea-National Institutes of Health registry, patients with OE accounted for 2.8% of all patients with stroke. The most common subtypes were arterial dissection (39.1%), cancer-related coagulopathy (17.3%), and intrinsic diseases of the arterial wall (16.7%). Overall, strokes of OE were more common in men than in women (58% versus 42%). Arterial dissection, intrinsic diseases of the arterial wall and stroke associated with migraine and drugs were more likely to occur at a young age, while disorders of platelets and the hemostatic system, cancer-related coagulopathy, infectious diseases, and hypoperfusion syndromes were more frequent at an old age. The composite of stroke and all-cause mortality within 1 year most frequently occurred in cancer-related coagulopathy, with an event rate of 71.8%, but least frequently occurred in stroke associated with migraine and drugs and arterial dissection, with event rates of 0% and 7.2%, respectively.
CONCLUSIONS:
This study presents the different characteristics, demographic findings, lesion locations, and outcomes of OE and its subtypes. It is characterized by a high proportion of arterial dissection, high mortality risk in cancer-related coagulopathy and an increasing annual frequency of cancer-related coagulopathy in patients with stroke of OE.
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Affiliation(s)
- Hyunsoo Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea (H.K., J.-T.K., M.-S.P., K.-H.C.)
- Department of Neurology, Ulsan University College of Medicine, Korea (H.K., W.-J.K.)
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea (H.K., J.-T.K., M.-S.P., K.-H.C.)
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (J.S.L.)
| | - Beom Joon Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (B.J.K., J.K., K.-J.L., H.-J.B.)
| | - Jihoon Kang
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (B.J.K., J.K., K.-J.L., H.-J.B.)
| | - Keon-Joo Lee
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (B.J.K., J.K., K.-J.L., H.-J.B.)
- Department of Neurology, Korea University Guro Hospital, Seoul (K.-J.L.)
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu-si, Korea (J.-M.P.)
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea (K.K.)
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, Korea (S.J.L., J.G.K.)
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, Korea (S.J.L., J.G.K.)
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K.)
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, Korea (J.-K.C., D.-H.K.)
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea (T.H.P.)
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, Korea (K.B.L.)
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Korea (J.L.)
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea (K.-S.H., Y.-J.C., H.-K.P.)
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea (K.-S.H., Y.-J.C., H.-K.P.)
| | - Hong-Kyun Park
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea (K.-S.H., Y.-J.C., H.-K.P.)
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (B.-C.L., K.-H.Y., M.S.O.)
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (B.-C.L., K.-H.Y., M.S.O.)
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (B.-C.L., K.-H.Y., M.S.O.)
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea (D.-E.K., W.-S.R.)
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea (D.-E.K., W.-S.R.)
- Artificial Intelligence Research Center, JLK, Inc., Seoul, Korea (W.-S.R.)
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea (J.C.C.)
| | | | - Wook-Joo Kim
- Department of Neurology, Ulsan University College of Medicine, Korea (H.K., W.-J.K.)
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea (D.-I.S., K.S.Y.)
| | - Kyu Sun Yum
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea (D.-I.S., K.S.Y.)
| | - Sung Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea (S.I.S., J.-H.H.)
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea (S.I.S., J.-H.H.)
| | - Sang-Hwa Lee
- Department of Neurology, Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon-si, Gangwon-do, Republic of Korea (S.-H.L.)
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea (H.K., J.-T.K., M.-S.P., K.-H.C.)
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea (H.K., J.-T.K., M.-S.P., K.-H.C.)
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea (J.L.)
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea (B.J.K., J.K., K.-J.L., H.-J.B.)
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9
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Kelley RE, Kelley BP. Heart-Brain Relationship in Stroke. Biomedicines 2021; 9:biomedicines9121835. [PMID: 34944651 PMCID: PMC8698726 DOI: 10.3390/biomedicines9121835] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/17/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022] Open
Abstract
The patient presenting with stroke often has cardiac-related risk factors which may be involved in the mechanism of the stroke. The diagnostic assessment is predicated on recognition of this potential relationship. Naturally, an accurate history is of utmost importance in discerning a possible cause and effect relationship. The EKG is obviously an important clue as well as it allows immediate assessment for possible cardiac arrhythmia, such as atrial fibrillation, for possible acute ischemic changes reflective of myocardial ischemia, or there may be indirect factors such as the presence of left ventricular hypertrophy, typically seen with longstanding hypertension, which could be indicative of a hypertensive mechanism for a patient presenting with intracerebral hemorrhage. For all presentations in the emergency room, the vital signs are important. An elevated body temperature in a patient presenting with acute stroke raises concern about possible infective endocarditis. An irregular-irregular pulse is an indicator of atrial fibrillation. A markedly elevated blood pressure is not uncommon in both the acute ischemic and acute hemorrhagic stroke setting. One tends to focus on possible cardioembolic stroke if there is the sudden onset of maximum neurological deficit versus the stepwise progression more characteristic of thrombotic stroke. Because of the more sudden loss of vascular supply with embolic occlusion, seizure or syncope at onset tends to be supportive of this mechanism. Different vascular territory involvement on neuroimaging is also a potential indicator of cardioembolic stroke. Identification of a cardiogenic source of embolus in such a setting certainly elevates this mechanism in the differential. There have been major advances in management of acute cerebrovascular disease in recent decades, such as thrombolytic therapy and endovascular thrombectomy, which have somewhat paralleled the advances made in cardiovascular disease. Unfortunately, the successful limitation of myocardial damage in acute coronary syndrome, with intervention, does not necessarily mirror a similar salutary effect on functional outcome with cerebral infarction. The heart can also affect the brain from a cerebral perfusion standpoint. Transient arrhythmias can result in syncope, while cardiac arrest can result in hypoxic-ischemic encephalopathy. Cardiogenic dementia has been identified as a mechanism of cognitive impairment associated with severe cardiac failure. Structural cardiac abnormalities can also play a role in brain insult, and this can include tumors, such as atrial myxoma, patent foramen ovale, with the potential for paradoxical cerebral embolism, and cardiomyopathies, such as Takotsubo, can be associated with precipitous cardioembolic events.
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Affiliation(s)
- Roger E. Kelley
- Ochsner/LSU Health Sciences Center, Department of Neurology, Shreveport, LA 71130, USA
- Correspondence:
| | - Brian P. Kelley
- Division of Cardiology, Department of Internal Medicine, University of North Carolina School of Medicine, Chapel Hill, NC 27514, USA;
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Yoo J, Kim YD, Park H, Kim BM, Bang OY, Kim HC, Han E, Kim DJ, Heo J, Kim M, Choi JK, Lee KY, Lee HS, Shin DH, Choi HY, Sohn SI, Hong JH, Lee JY, Baek JH, Kim GS, Seo WK, Chung JW, Kim SH, Song TJ, Han SW, Park JH, Kim J, Jung YH, Cho HJ, Ahn SH, Lee SI, Seo KD, Heo JH, Nam HS. Immediate and Long-Term Outcomes of Reperfusion Therapy in Patients With Cancer. Stroke 2021; 52:2026-2034. [PMID: 33910369 DOI: 10.1161/strokeaha.120.032380] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Joonsang Yoo
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Yongin Severance Hospital (J.Y., J.K.), Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
| | - Hyungjong Park
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea (H.P., S.-I.S., J.-H.H.)
| | - Byung Moon Kim
- Department of Radiology (B.M.K., D.J.K.), Yonsei University College of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (O.Y.B., W.-K.S., J.-W.C.)
| | - Hyeon Chang Kim
- Department of Preventive Medicine (H.C.K.), Yonsei University College of Medicine, Seoul, Korea
| | - Euna Han
- College of Pharmacy, Yonsei Institute for Pharmaceutical Research, Yonsei University, Incheon, South Korea (E.H.)
| | - Dong Joon Kim
- Department of Radiology (B.M.K., D.J.K.), Yonsei University College of Medicine, Seoul, Korea
| | - Joonnyung Heo
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
| | - Minyoung Kim
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyo Choi
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Severance Institute for Vascular and Metabolic Research (K.-Y.L., Y.H.J.), Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Department of Research Affairs (H.S.L.), Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hoon Shin
- Department of Neurology, Gachon University Gil Medical Center, Incheon, Korea (D.H.S.)
| | - Hye-Yeon Choi
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea (H.-Y.C.)
| | - Sung-Il Sohn
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea (H.P., S.-I.S., J.-H.H.)
| | - Jeong-Ho Hong
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea (H.P., S.-I.S., J.-H.H.)
| | - Jong Yun Lee
- Department of Neurology, National Medical Center, Seoul, Korea (J.Y.L., J.-H.B.)
| | - Jang-Hyun Baek
- Department of Neurology, National Medical Center, Seoul, Korea (J.Y.L., J.-H.B.).,Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (J.-H.B.)
| | - Gyu Sik Kim
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea (G.S.K., K.-D.S.)
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (O.Y.B., W.-K.S., J.-W.C.)
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (O.Y.B., W.-K.S., J.-W.C.)
| | - Seo Hyun Kim
- Department of Neurology, Yonsei University Wonju College of Medicine, Korea (S.H.K.)
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, College of Medicine, Ewha Woman's University, Korea (T.-J.S.)
| | - Sang Won Han
- Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea (S.W.H., J.H.P.)
| | - Joong Hyun Park
- Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea (S.W.H., J.H.P.)
| | - Jinkwon Kim
- Department of Neurology, Yongin Severance Hospital (J.Y., J.K.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam, Korea (J.K.)
| | - Yo Han Jung
- Department of Neurology, Gangnam Severance Hospital, Severance Institute for Vascular and Metabolic Research (K.-Y.L., Y.H.J.), Yonsei University College of Medicine, Seoul, Korea.,Department of Neurology, Changwon Fatima Hospital, Korea (Y.H.J.)
| | - Han-Jin Cho
- Department of Neurology, Pusan National University School of Medicine, Busan, Korea (H.-J.C.)
| | - Seong Hwan Ahn
- Department of Neurology, Chosun University School of Medicine, Gwangju, Korea (S.H.A.)
| | - Sung Ik Lee
- Department of Neurology, Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea (S.I.L., K.-D.S.)
| | - Kwon-Duk Seo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea (G.S.K., K.-D.S.).,Department of Neurology, Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea (S.I.L., K.-D.S.)
| | | | - Hyo Suk Nam
- Department of Neurology (J.Y., Y.D.K., H.P., J.H., M.K., J.K.C., J.H.H., H.S.N.), Yonsei University College of Medicine, Seoul, Korea
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