When to Screen Ischaemic Stroke Patients for Cancer

BACKGROUND AND PURPOSE

Ischemic stroke can be the first manifestation of cancer and it is therefore important to ascertain which stroke patients should be considered for cancer-diagnostic investigations. We aimed to determine the frequency of active cancer in patients with acute ischemic stroke and to compare clinical findings in stroke patients with active cancer to ischemic stroke patients with no history of cancer. Finally, we aimed to develop a predictive and feasible score for clinical use to uncover underlying malignancy.

METHODS

All ischemic stroke patients admitted to the stroke unit in the Department of Neurology, Haukeland University Hospital were consecutively included in the Norwegian Stroke Research Registry (NORSTROKE). Stroke etiology was determined by the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Data on cancer diagnoses was obtained from patients' medical records and the Cancer Registry of Norway. Active cancer was defined as cancer diagnosis, metastasis of known cancer, recurrent cancer or receiving cancer treatment, all within 12 months before or after the index stroke. Based on variables independently associated with active cancer, a predictive score was developed using the area under the receiver operating characteristic (AUC-ROC) curves. Bayes' theorem was used to calculate post-test probabilities of active cancer.

RESULTS

Of the 1,646 ischemic stroke patients included, 82 (5.0%) had active cancer. Increased D-dimer (OR = 1.1, 95% CI: 1.1-1.2, p = <0.001), lower Hb (OR = 0.6, 95% CI: 0.5-0.7, p = <0.001), smoking (OR = 2.2, 95% CI: 1.2-4.3, p = 0.02) and suffering a stroke of undetermined etiology (OR = 1.9, 95% CI: 1.1-3.3, p = 0.03) were factors independently associated with active cancer. These were included in the final predictive score which gave an AUC of 0.73 (95% CI: 0.65-0.81) in patients younger than 75 years of age. Assuming the prevalence of cancer to be 5%, the score shows that if a patient fulfills all 3 score points, the probability of active cancer is 53%.

CONCLUSIONS

Active cancer was found in 5% of our ischemic stroke patients. We found that a clinical score comprising elevated D-dimer ≥3 mg/L, lower Hb ≤12.0 g/dL and previous or current smoking is feasible for predicting active cancer in ischemic stroke patients.

Has the aetiology of ischaemic stroke changed in the past decades? Analysis and comparison of data from current and historical stroke databases

OBJECTIVES

We aimed to determine whether the aetiology of ischaemic stroke has changed in recent years and, if so, to ascertain the possible reasons for these changes.

PATIENTS AND METHODS

We analysed the epidemiological history and vascular risk factors of all patients diagnosed with ischaemic stroke at Complejo Hospitalario Universitario de Albacete (CHUA) from 2009 to 2014. Ischaemic stroke subtypes were established using the TOAST criteria. Our results were compared to data from the classic Stroke Data Bank (SDB); in addition, both series were compared to those of other hospital databases covering the period between the two.

RESULTS

We analysed 1664 patients (58% were men) with a mean age of 74 years. Stroke aetiology in both series (CHUA, SDB) was as follows: atherosclerosis (12%, 9%), small-vessel occlusion (13%, 25%), cardioembolism (32%, 19%), stroke of other determined aetiology (3%, 4%), and stroke of undetermined aetiology (40%, 44%). Sixty-three percent of the patients from the CHUA and 42% of the patients from the SDB were older than 70 years. Cardioembolic strokes were more prevalent in patients older than 70 years in both series. Untreated hypertension was more frequent in the SDB (SDB = 31% vs CHUA = 10%). The analysis of other databases shows that the prevalence of cardioembolic stroke is increasing worldwide.

CONCLUSIONS

Our data show that the prevalence of lacunar strokes is decreasing worldwide whereas cardioembolic strokes are increasingly more frequent in both our hospital and other series compared to the SDB. These differences may be explained by population ageing and the improvements in management of hypertension and detection of cardioembolic arrhythmias in stroke units.