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Wattana MK, Lindsay A, Davenport M, Pettit NR, Menendez JR, Li Z, Lipe DN, Qdaisat A, Bischof JJ. Current gaps in emergency medicine core content education for oncologic emergencies: A targeted needs assessment. AEM EDUCATION AND TRAINING 2024; 8:e10987. [PMID: 38765712 PMCID: PMC11099727 DOI: 10.1002/aet2.10987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/02/2024] [Accepted: 04/04/2024] [Indexed: 05/22/2024]
Abstract
Objective The core content of emergency medicine (EM) residency training includes the management of oncologic emergencies; however, documented knowledge gaps continue to exist in this subtopic. This study represents a targeted needs assessment as indicated by Step 2 of Kern's curriculum design to determine the specific training gaps to be addressed within the oncologic EM curriculum. Methods A multi-institutional cross-sectional survey of oncologists (surgical and medical) and emergency physicians (attendings and residents) was conducted during 2023 at five institutions. The voluntary survey consisted of general and specialty-specific questions exploring gaps in oncologic emergency-specific training/education topics. Descriptive statistics reported responses as frequencies and percentages. Results Of the 833 surveys sent across the five sites, 302 (36.3%) were accessed by link; of these, 271 (89.7%) surveys were completed. There were no differences in the responses between early and later respondents and no differences in the characteristics of respondents between sites. A vast majority of the oncologist and EM groups (91.2% and 83.0%, respectively) reported a belief that emergency physicians would benefit from additional oncologic emergency training. Our survey identified 16 important topics for inclusion in an oncologic EM curriculum, including five topics not present on the 2022 Model of Clinical Practice of Emergency Medicine. Conclusions Based on this needs assessment, an oncologic EM curriculum should include the topics listed under oncologic emergencies in the 2022 Model of the Clinical Practice of Emergency Medicine along with our respondent-identified topics of radiation therapy adverse effects, stem cell transplant complications, and the management of cancer-specific postsurgical complications, pain, and common diseases in patients with cancer.
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Affiliation(s)
- Monica K. Wattana
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Angela Lindsay
- Department of Emergency MedicineVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Moira Davenport
- Department of Emergency MedicineAllegheny General Hospital/Allegheny Health NetworkPittsburghPennsylvaniaUSA
| | - Nicholas R. Pettit
- Department of Emergency MedicineIndiana UniversityIndianapolisIndianaUSA
| | - Jazmin R. Menendez
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Ziyi Li
- Department of BiostatisticsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | | | - Aiham Qdaisat
- Department of Emergency MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Jason J. Bischof
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
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Sawada J, Katayama T, Kikuchi-Takeguchi S, Kano K, Saito M, Mitsui N, Hiroshima S, Kinoshita M, Nakagawa N. Clinical features and prognostic factors of patients with cancer-associated stroke. Neurol Sci 2024; 45:2747-2757. [PMID: 38267601 DOI: 10.1007/s10072-024-07332-y] [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: 09/22/2023] [Accepted: 01/12/2024] [Indexed: 01/26/2024]
Abstract
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.
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Affiliation(s)
- Jun Sawada
- Division of Cardiology, Nephrology, Pulmonology, and Neurology, Department of Internal Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.
| | - Takayuki Katayama
- Department of Neurology, Asahikawa City Hospital, Asahikawa, Hokkaido, Japan
| | - Shiori Kikuchi-Takeguchi
- Division of Cardiology, Nephrology, Pulmonology, and Neurology, Department of Internal Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Kohei Kano
- Division of Cardiology, Nephrology, Pulmonology, and Neurology, Department of Internal Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Masato Saito
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Nobuyuki Mitsui
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Satoru Hiroshima
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Manabu Kinoshita
- Department of Neurosurgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Naoki Nakagawa
- Division of Cardiology, Nephrology, Pulmonology, and Neurology, Department of Internal Medicine, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
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Wang Q, Fu W, Wang F. Malignant tumor increases the risk of all causes in-hospital mortality in critically ill patients with ischemic stroke: analysis of the MIMIC-IV database. BMC Neurol 2024; 24:178. [PMID: 38802785 PMCID: PMC11129437 DOI: 10.1186/s12883-024-03690-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 05/23/2024] [Indexed: 05/29/2024] Open
Abstract
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.
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Affiliation(s)
- Qiwei Wang
- Department of Neurology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, P.R. China
| | - Wang Fu
- Department of Neurology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, P.R. China
| | - Feng Wang
- Department of Neurology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, P.R. China.
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4
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Ntaios G, Baumgartner H, Doehner W, Donal E, Edvardsen T, Healey JS, Iung B, Kamel H, Kasner SE, Korompoki E, Navi BB, Pristipino C, Saba L, Schnabel RB, Svennberg E, Lip GYH. Embolic strokes of undetermined source: a clinical consensus statement of the ESC Council on Stroke, the European Association of Cardiovascular Imaging and the European Heart Rhythm Association of the ESC. Eur Heart J 2024; 45:1701-1715. [PMID: 38685132 PMCID: PMC11107123 DOI: 10.1093/eurheartj/ehae150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
One in six ischaemic stroke patients has an embolic stroke of undetermined source (ESUS), defined as a stroke with unclear aetiology despite recommended diagnostic evaluation. The overall cardiovascular risk of ESUS is high and it is important to optimize strategies to prevent recurrent stroke and other cardiovascular events. The aim of clinicians when confronted with a patient not only with ESUS but also with any other medical condition of unclear aetiology is to identify the actual cause amongst a list of potential differential diagnoses, in order to optimize secondary prevention. However, specifically in ESUS, this may be challenging as multiple potential thromboembolic sources frequently coexist. Also, it can be delusively reassuring because despite the implementation of specific treatments for the individual pathology presumed to be the actual thromboembolic source, patients can still be vulnerable to stroke and other cardiovascular events caused by other pathologies already identified during the index diagnostic evaluation but whose thromboembolic potential was underestimated. Therefore, rather than trying to presume which particular mechanism is the actual embolic source in an ESUS patient, it is important to assess the overall thromboembolic risk of the patient through synthesis of the individual risks linked to all pathologies present, regardless if presumed causally associated or not. In this paper, a multi-disciplinary panel of clinicians/researchers from various backgrounds of expertise and specialties (cardiology, internal medicine, neurology, radiology and vascular surgery) proposes a comprehensive multi-dimensional assessment of the overall thromboembolic risk in ESUS patients through the composition of individual risks associated with all prevalent pathologies.
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Affiliation(s)
- George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Larissa 41132, Greece
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Wolfram Doehner
- Department of Cardiology (Campus Virchow), Center of Stroke Research Berlin, German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin Institute of Health-Center for Regenerative Therapies, Deutsches Herzzentrum der Charité, Charité, Berlin, Germany
| | - Erwan Donal
- Service de Cardiologie et CIC-IT 1414, CHU Rennes, Rennes, France
| | - Thor Edvardsen
- Department of Cardiology, Faculty of Medicine, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway
| | - Jeff S Healey
- Cardiology Division, McMaster University, Hamilton, Canada
| | - Bernard Iung
- Bichat Hospital, APHP and Université Paris-Cité, INSERM LVTS U1148, Paris, France
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Scott E Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eleni Korompoki
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian Pristipino
- Interventional and Intensive Cardiology Unit, San Filippo Neri Hospital, ASL Roma 1, Rome, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari—Polo di Monserrato, Cagliari, Italy
| | - Renate B Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany
| | - Emma Svennberg
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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5
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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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Kim K, Di Giovanna E, Jung H, Bethineedi LD, Jun TJ, Kim YH. Association of metabolic health and obesity with coronary heart disease in adult cancer survivors. Eur J Clin Invest 2024; 54:e14161. [PMID: 38239087 DOI: 10.1111/eci.14161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/26/2023] [Accepted: 01/05/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND The metabolically healthy obese (MHO) phenotype is associated with an increased risk of coronary heart disease (CHD) in the general population. However, association of metabolic health and obesity phenotypes with CHD risk in adult cancer survivors remains unclear. We aimed to investigate the associations between different metabolic health and obesity phenotypes with incident CHD in adult cancer survivors. METHODS We used National Health Insurance Service (NHIS) to identify a cohort of 173,951 adult cancer survivors aged more than 20 years free of cardiovascular complications. Metabolically healthy nonobese (MHN), MHO, metabolically unhealthy nonobese (MUN), metabolically unhealthy obese (MUO) phenotypes were created using as at least three out of five metabolic health criteria along with obesity (body mass index ≥ 25.0 kg/m2). We used Cox proportional hazards model to assess CHD risk in each metabolic health and obesity phenotypes. RESULTS During 1,376,050 person-years of follow-up, adult cancer survivors with MHO phenotype had a significantly higher risk of CHD (hazard ratio [HR] = 1.52; 95% confidence intervals [CI]: 1.41 to 1.65) as compared to those without obesity and metabolic abnormalities. MUN (HR = 1.81; 95% CI: 1.59 to 2.06) and MUO (HR = 1.92; 95% CI: 1.72 to 2.15) phenotypes were also associated with an increased risk of CHD among adult cancer survivors. CONCLUSIONS Adult cancer survivors with MHO phenotype had a higher risk of CHD than those who are MHN. Metabolic health status and obesity were jointly associated with CHD risk in adult cancer survivors.
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Affiliation(s)
- Kyuwoong Kim
- National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
- Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Republic of Korea
| | - Edvige Di Giovanna
- Department of Diagnostic and Interventional Radiology, Ammerland-Klinik, Westerstede, Lower Saxony, Germany
| | - Hyeyun Jung
- Department of Computing, Newcastle University, Newcastle upon Tyne, UK
| | | | - Tae Joon Jun
- Big Data Research Center, Asan Institute for Life Science, Asan Medical Center, Seoul, Republic of Korea
| | - Young-Hak Kim
- Big Data Research Center, Asan Institute for Life Science, Asan Medical Center, Seoul, Republic of Korea
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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7
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van Dorth D, Jiang FY, Schmitz-Abecassis B, Croese RJI, Taphoorn MJB, Smits M, Koekkoek JAF, Dirven L, de Bresser J, van Osch MJP. Influence of arterial transit time delays on the differentiation between tumor progression and pseudoprogression in glioblastoma by arterial spin labeling magnetic resonance imaging. NMR IN BIOMEDICINE 2024:e5166. [PMID: 38654579 DOI: 10.1002/nbm.5166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/26/2024]
Abstract
Arterial spin labeling (ASL) and dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI) have shown potential for differentiating tumor progression from pseudoprogression. For pseudocontinuous ASL with a single postlabeling delay, the presence of delayed arterial transit times (ATTs) could affect the evaluation of ASL-MRI perfusion data. In this study, the influence of ATT artifacts on the perfusion assessment and differentiation between tumor progression and pseudoprogression were studied. This study comprised 66 adult patients (mean age 60 ± 13 years; 40 males) with a histologically confirmed glioblastoma who received postoperative radio (chemo)therapy. ASL-MRI and DSC-MRI scans were acquired at 3 months postradiotherapy as part of the standard clinical routine. These scans were visually scored regarding (i) the severity of ATT artifacts (%) on the ASL-MRI scans only, scored by two neuroradiologists; (ii) perfusion of the enhancing tumor lesion; and (iii) radiological evaluation of tumor progression versus pseudoprogression by one neuroradiologist. The final outcome was based on combined clinical and radiological follow-up until 9 months postradiotherapy. ATT artifacts were identified in all patients based on the mean scores of two raters. A significant difference between the radiological evaluation of ASL-MRI and DSC-MRI was observed only for ASL images with moderate ATT severity (30%-65%). The perfusion assessment showed ASL-MRI tending more towards hyperperfusion than DSC-MRI in the case of moderate ATT artifacts. In addition, there was a significant difference between the prediction of tumor progression with ASL-MRI and the final outcome in the case of severe ATT artifacts (McNemar test, p = 0.041). Despite using ASL imaging parameters close to the recommended settings, ATT artifacts frequently occur in patients with treated brain tumors. Those artifacts could hinder the radiological evaluation of ASL-MRI data and the detection of true disease progression, potentially affecting treatment decisions for patients with glioblastoma.
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Affiliation(s)
- Daniëlle van Dorth
- C. J. Gorter MRI Center, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Feng Yan Jiang
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Radiology, HagaZiekenhuis, Den Haag, The Netherlands
| | - Bárbara Schmitz-Abecassis
- C. J. Gorter MRI Center, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Medical Delta, Delft, The Netherlands
| | - Robert J I Croese
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Marion Smits
- Medical Delta, Delft, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Brain Tumor Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Johan A F Koekkoek
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Matthias J P van Osch
- C. J. Gorter MRI Center, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Medical Delta, Delft, The Netherlands
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Gon Y, Morishima T, Kawano T, Okazaki S, Todo K, Sasaki T, Mochizuki H, Miyashiro I. Arterial Thromboembolism in Japanese Patients With Cancer: Incidence, Predictors, and Survival Impact. JACC CardioOncol 2024; 6:283-297. [PMID: 38774004 PMCID: PMC11103032 DOI: 10.1016/j.jaccao.2024.01.006] [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: 09/08/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 05/24/2024] Open
Abstract
Background Thromboembolism is a significant complication for patients with cancer, leading to treatment interruptions and poor outcomes. Objectives The aim of this study was to investigate the incidence of arterial thromboembolism (ATE) within cancer populations, identify the predictors of ATE, and determine its survival impact. Methods A retrospective multicenter study was performed using data from the Osaka Cancer Registry linked with administrative data from 2010 to 2015. Patients were monitored for 5 years after cancer diagnosis, and ATE incidence was calculated with death as a competing risk. Fine and Gray competing risk regression models and Cox proportional hazards models were used to evaluate the predictors of ATE and the survival impact. Restricted mean survival time (RMST) was used to assess whether antithrombotic therapy after ATE contributed to improved survival. Results The cohort comprised 97,448 patients with cancer (42.3% women, median age 70 years). ATE incidence displayed an annual increase, peaking 1 year after cancer diagnosis (1-, 2-, 3-, 4-, and 5-year cumulative incidences were 1.29%, 1.77%, 2.05%, 2.22%, and 2.32%, respectively). Male sex, advanced age, advanced cancer stage, and hematologic malignancies correlated with a high risk for ATE. Patients with ATE had a 2-fold increased risk for mortality compared with those without ATE. The 90-day and 1-year RMST differences for those on antithrombotic therapy were 13.3 days (95% CI: 10.4-16.2 days; P < 0.001) and 57.8 days (95% CI: 43.1-72.5 days; P < 0.001), favoring the antithrombotic therapy group. The RMST differences varied by cancer stage. Conclusions The risk for ATE varies according to sex, age, and cancer progression and type. Antithrombotic therapy after ATE is associated with improved survival among patients with cancer.
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Affiliation(s)
- Yasufumi Gon
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
| | | | - Tomohiro Kawano
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
- StemRIM Institute of Regeneration-Inducing Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Isao Miyashiro
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
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Costamagna G, Hottinger AF, Milionis H, Salerno A, Strambo D, Livio F, Navi BB, Michel P. Acute ischaemic stroke in active cancer versus non-cancer patients: stroke characteristics, mechanisms and clinical outcomes. Eur J Neurol 2024; 31:e16200. [PMID: 38235924 DOI: 10.1111/ene.16200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND PURPOSE Demographics, clinical characteristics, stroke mechanisms and long-term outcomes were compared between acute ischaemic stroke (AIS) patients with active cancer (AC) versus non-cancer patients. METHODS Using data from 2003 to 2021 in the Acute STroke Registry and Analysis of Lausanne, a retrospective cohort study was performed comparing patients with AC, including previously known and newly diagnosed cancers, with non-cancer patients. Patients with inactive cancer were excluded. Outcomes were the modified Rankin Scale (mRS) score at 3 months, death and cerebrovascular recurrences at 12 months before and after propensity score matching. RESULTS Amongst 6686 patients with AIS, 1065 (15.9%) had a history of cancer. After excluding 700 (10.4%) patients with inactive cancer, there were 365 (5.5%) patients with AC and 5621 (84%) non-cancer AIS patients. Amongst AC patients, 154 (42.2%) strokes were classified as cancer related. In multivariable analysis, patients with AC were older (adjusted odds ratio [aOR] 1.02, 95% confidence interval [CI] 1.00-1.03), had fewer vascular risk factors and were 48% less likely to receive reperfusion therapies (aOR 0.52, 95% CI 0.35-0.76). Three-month mRS scores were not different in AC patients (aOR 2.18, 95% CI 0.96-5.00). At 12 months, death (adjusted hazard ratio 1.91, 95% CI 1.50-2.43) and risk of cerebrovascular recurrence (sub-distribution hazard ratio 1.68, 95% CI 1.22-2.31) before and after propensity score matching were higher in AC patients. CONCLUSIONS In a large institutional registry spanning nearly two decades, AIS patients with AC had less past cerebrovascular disease but a higher 1-year risk of subsequent death and cerebrovascular recurrence compared to non-cancer patients. Antithrombotic medications at discharge may reduce this risk in AC patients.
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Affiliation(s)
- Gianluca Costamagna
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Dino Ferrari Centre, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Milan, Italy
| | - Andreas F Hottinger
- Lundin and Family Brain Tumor Research Center, Services of Neurology and Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haralampos Milionis
- First Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Francoise Livio
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Babak B Navi
- Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York City, New York, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Naftali J, Barnea R, Eliahou R, Pardo K, Tolkovsky A, Adi M, Hasminski V, Saliba W, Bloch S, Raphaeli G, Leader A, Auriel E. Lung cancer is associated with acute ongoing cerebral ischemia: A population-based study. Int J Stroke 2024; 19:406-413. [PMID: 37978833 DOI: 10.1177/17474930231217670] [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] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Cerebral microinfarcts (CMIs) are the most common type of brain ischemia; however, they are extremely rare in the general population. CMIs can be detected by magnetic resonance diffusion-weighted imaging (MRI-DWI) only for a very short period of approximately 2 weeks after their formation and are associated with an increased stroke risk and cognitive impairment. We aimed to examine CMI detection rate in patients with lung cancer (LC), which is strongly associated with ischemic stroke risk relative to other cancer types. METHODS We used the Clalit Health Services record (representing more than 5 million patients) to identify adults with LC and breast, pancreatic, or colon cancer (non-lung cancer, NLC) who underwent brain magnetic resonance diffusion (MRI) scan within 5 years following cancer diagnosis. All brain MRI scans were reviewed, and CMIs were documented, as well as cardiovascular risk factors. RESULTS Our cohort contained a total of 2056 MRI scans of LC patients and 1598 of NLC patients. A total of 143 CMI were found in 73/2056 (3.5%) MRI scans of LC group compared to a total of 29 CMI in 22/1598 (1.4%) MRI scans of NLC (p < 0.01). Cancer type (e.g. LC vs NLC) was the only associated factor with CMI incidence on multivariate analysis. After calculating accumulated risk, we found an incidence of 2.5 CMI per year in LC patients and 0.5 in NLC. DISCUSSION CMIs are common findings in cancer patients, especially in LC patients and therefore might serve as a marker for occult brain ischemia, cognitive decline, and cancer-related stroke (CRS) risk.
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Affiliation(s)
- Jonathan Naftali
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Rani Barnea
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ruth Eliahou
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Department of Radiology, Rabin Medical Center, Petach Tikva, Israel
| | - Keshet Pardo
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Assaf Tolkovsky
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Meital Adi
- Department of Radiology, Kaplan Medical Center, Rehovot, Israel
| | - Vadim Hasminski
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Department of Radiology, Rabin Medical Center, Petach Tikva, Israel
| | - Walid Saliba
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Sivan Bloch
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Neurology, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Guy Raphaeli
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Avi Leader
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Eitan Auriel
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
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11
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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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12
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Baker R, Bakali Z, Crocker JS, Mowla A, Smith M, Grossman A, Hagen MC, Prestigiacomo CJ, Shirani P. Tumor Embolic Stroke: The Importance of Pathological Assessment of Clots after Thrombectomy. J Clin Med 2024; 13:1834. [PMID: 38610599 PMCID: PMC11012646 DOI: 10.3390/jcm13071834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/14/2024] Open
Abstract
While tumor emboli are a rare cause of stroke in cancer patients, they highlight the importance of gross observations and pathological assessments in the evaluation of clots. In this case report, a 70-year-old male with type 2 diabetes mellitus and coronary artery disease presented with acute left-sided weakness. He was clinically diagnosed with stroke and given alteplase at 1.5 h from last known normal. He then underwent CT angiography that showed right internal carotid artery occlusion and immediate thrombectomy. The recovered clot was white and lipid-like; due to its atypical appearance, it was sent for pathological assessment, where it was shown to bear features of malignancy. Subsequent imaging identified masses indicating malignancy in the left gluteus, right pleural hilum, and spine. Tumor embolic stroke is a rare pathology. Embolic diseases such as strokes and pulmonary embolisms are common in patients with cancer. Embolic stroke of undetermined source (ESUS) represents a significant portion of cancer strokes. Tumor emboli, though rare, may be an underappreciated source of ESUS in cancer patients. We intend for this case to demonstrate the value of pathological assessment for atypical thrombi as well as highlight the etiology of tumor embolic strokes.
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Affiliation(s)
- Richard Baker
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
| | - Zohabe Bakali
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
| | - Jeffrey S. Crocker
- Department of Pharmacology & Systems Physiology, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Ashkan Mowla
- Department of Neurosurgery, University of Southern California, Los Angeles, CA 90033, USA;
| | - Matthew Smith
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Neurology & Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Aaron Grossman
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Neurology & Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Matthew C. Hagen
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Pathology & Laboratory Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH 45221, USA
| | - Charles J. Prestigiacomo
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Peyman Shirani
- College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA (M.C.H.)
- Department of Neurology & Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
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13
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Xie W, Hsu S, Lin Y, Xie L, Jin X, Zhu Z, Guo Y, Chen C, Huang D, Boltze J, Li P. Malignancy-associated ischemic stroke: Implications for diagnostic and therapeutic workup. CNS Neurosci Ther 2024; 30:e14619. [PMID: 38532275 PMCID: PMC10965754 DOI: 10.1111/cns.14619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Patients with malignancies have an increased risk of suffering ischemic stroke via several mechanisms such as coagulation dysfunction and other malignancy-related effects as well as iatrogenic causes. Moreover, stroke can be the first sign of an occult malignancy, termed as malignancy-associated ischemic stroke (MAS). Therefore, timely diagnostic assessment and targeted management of this complex clinical situation are critical. FINDINGS Patients with both stroke and malignancy have atypical ages, risk factors, and often exhibit malignancy-related symptoms and multiple lesions on neuroimaging. New biomarkers such as eicosapentaenoic acid and blood mRNA profiles may help in distinguishing MAS from other strokes. In terms of treatment, malignancy should not be considered a contraindication, given comparable rates of recanalization and complications between stroke patients with or without malignancies. CONCLUSION In this review, we summarize the latest developments in diagnosing and managing MAS, especially stroke with occult malignancies, and provide new recommendations from recently emerged clinical evidence for diagnostic and therapeutic workup strategies.
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Affiliation(s)
- Wanqing Xie
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Szuyao Hsu
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yuxuan Lin
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Lv Xie
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Xia Jin
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Ziyu Zhu
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yunlu Guo
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Caiyang Chen
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Dan Huang
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | | | - Peiying Li
- Department of Anesthesiology, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Clinical Research Center, Renji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Outcomes Research ConsortiumClevelandOhioUSA
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14
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Shaw JR, Li N, Abdulrehman J, Stella SF, St John M, Nixon J, Spyropoulos AC, Schulman S, Wang TF, Carrier M, Douketis JD. Periprocedural management of direct oral anticoagulants in patients with atrial fibrillation and active cancer. J Thromb Haemost 2024; 22:727-737. [PMID: 37949316 DOI: 10.1016/j.jtha.2023.10.028] [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: 09/22/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Cancer and atrial fibrillation (AF) are common concurrent disorders. Direct oral anticoagulants (DOACs) are prescribed to prevent stroke in patients with AF. Patients with cancer often undergo invasive procedures for diagnostic or therapeutic purposes, necessitating interruption of anticoagulation. There are limited data to guide best periprocedural anticoagulation management practices in the setting of active cancer. OBJECTIVES To describe patient characteristics, periprocedural management, and clinical outcomes in DOAC-treated patients with AF according to active cancer status. METHODS We conducted descriptive and comparative analyses using data from the PAUSE study. Multivariable logistic regression was used to determine whether active cancer status was an independent risk factor for bleeding outcomes. Covariates were selected a priori based on biological rationale and preexisting knowledge. RESULTS Patients with active cancer were older (P < .001), more likely to be thrombocytopenic (P = .026), have moderate renal dysfunction (P = .005), and more likely to receive low-dose DOAC therapy (P < .001). A greater proportion of patients with active cancer underwent a high-bleed-risk procedure (P < .001), with longer periprocedural DOAC-interruption intervals (P <.001) and lower preprocedural residual DOAC levels (P = .002). Active cancer was an independent predictor for surgical major bleeding (OR = 2.45; 95% CI, 1.08-5.14) after adjusting for study center, procedure category and bleed risk, thrombocytopenia, hypertension, and the use of a P2Y12 inhibitor. CONCLUSIONS Active cancer status is associated with an increased risk of surgical major bleeding among DOAC-treated patients with AF undergoing interruption of anticoagulation for elective invasive procedures.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Na Li
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Department of Computing and Software, McMaster University, Hamilton, ON, Canada
| | | | | | - Melanie St John
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Joanne Nixon
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, New York, USA. https://twitter.com/AlexSpyropoul
| | - Sam Schulman
- Department of Obstetrics and Gynecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Tzu-Fei Wang
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, ON, Canada. https://twitter.com/TzufeiWang
| | - Marc Carrier
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, ON, Canada. https://twitter.com/MarcCarrier1
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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15
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Fang J, Wu J, Hong G, Zheng L, Yu L, Liu X, Lin P, Yu Z, Chen D, Lin Q, Jing C, Zhang Q, Wang C, Zhao J, Yuan X, Wu C, Zhang Z, Guo M, Zhang J, Zheng J, Lei A, Zhang T, Lan Q, Kong L, Wang X, Wang Z, Ma Q. Cancer screening in hospitalized ischemic stroke patients: a multicenter study focused on multiparametric analysis to improve management of occult cancers. EPMA J 2024; 15:53-66. [PMID: 38463627 PMCID: PMC10923752 DOI: 10.1007/s13167-024-00354-8] [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: 10/19/2023] [Accepted: 02/02/2024] [Indexed: 03/12/2024]
Abstract
Background/aims The reciprocal promotion of cancer and stroke occurs due to changes in shared risk factors, such as metabolic pathways and molecular targets, creating a "vicious cycle." Cancer plays a direct or indirect role in the pathogenesis of ischemic stroke (IS), along with the reactive medical approach used in the treatment and clinical management of IS patients, resulting in clinical challenges associated with occult cancer in these patients. The lack of reliable and simple tools hinders the effectiveness of the predictive, preventive, and personalized medicine (PPPM/3PM) approach. Therefore, we conducted a multicenter study that focused on multiparametric analysis to facilitate early diagnosis of occult cancer and personalized treatment for stroke associated with cancer. Methods Admission routine clinical examination indicators of IS patients were retrospectively collated from the electronic medical records. The training dataset comprised 136 IS patients with concurrent cancer, matched at a 1:1 ratio with a control group. The risk of occult cancer in IS patients was assessed through logistic regression and five alternative machine-learning models. Subsequently, select the model with the highest predictive efficacy to create a nomogram, which is a quantitative tool for predicting diagnosis in clinical practice. Internal validation employed a ten-fold cross-validation, while external validation involved 239 IS patients from six centers. Validation encompassed receiver operating characteristic (ROC) curves, calibration curves, decision curve analysis (DCA), and comparison with models from prior research. Results The ultimate prediction model was based on logistic regression and incorporated the following variables: regions of ischemic lesions, multiple vascular territories, hypertension, D-dimer, fibrinogen (FIB), and hemoglobin (Hb). The area under the ROC curve (AUC) for the nomogram was 0.871 in the training dataset and 0.834 in the external test dataset. Both calibration curves and DCA underscored the nomogram's strong performance. Conclusions The nomogram enables early occult cancer diagnosis in hospitalized IS patients and helps to accurately identify the cause of IS, while the promotion of IS stratification makes personalized treatment feasible. The online nomogram based on routine clinical examination indicators of IS patients offered a cost-effective platform for secondary care in the framework of PPPM. Supplementary Information The online version contains supplementary material available at 10.1007/s13167-024-00354-8.
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Affiliation(s)
- Jie Fang
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
- School of Medicine, Xiamen University, Xiamen, China
| | - Jielong Wu
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- School of Medicine, Xiamen University, Xiamen, China
- National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen, China
| | - Ganji Hong
- Cerebrovascular Interventional Department, Zhangzhou Hospital of Fujian Province, Zhangzhou, China
| | - Liangcheng Zheng
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Lu Yu
- Department of Neurology, Changxing People’s Hospital, Huzhou, China
| | - Xiuping Liu
- Department of Neurology, The Jilin Center Hospital, Jilin, China
| | - Pan Lin
- Department of Neurology, The Second Hospital of Longyan City, Longyan, China
| | - Zhenzhen Yu
- Department of Neurology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Dan Chen
- Department of Neurology, Xiamen Haicang Hospital, Xiamen, China
| | - Qing Lin
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Chuya Jing
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Qiuhong Zhang
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Chen Wang
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | - Jiedong Zhao
- School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Xiaodong Yuan
- Department of Gynecology of Xiamen Maternal and Child Health Care Hospital, Xiamen, China
| | - Chunfang Wu
- Department of Neurology, Huaihe Hospital, Henan University, Huaihe, China
| | - Zhaojie Zhang
- Department of Neurology, Kaifeng Hospital of Traditional Chinese Medicine, Kaifeng, China
| | - Mingwei Guo
- Department of Neurology, First Affiliated Hospital of Gannan Medical University, Gannan, China
| | - Junde Zhang
- Department of Neurology, First Affiliated Hospital of Gannan Medical University, Gannan, China
| | - Jingjing Zheng
- Department of Neurology, Ningde Municipal Hospital of Ningde Normal University, Ningde, China
| | - Aidi Lei
- Department of Neurology, The Fifth Hospital of Xiamen, Xiamen, China
| | - Tengkun Zhang
- Department of Neurology, The Fifth Hospital of Xiamen, Xiamen, China
| | - Quan Lan
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
| | | | - Xinrui Wang
- NHC Key Laboratory of Technical Evaluation of Fertility Regulation for Non-Human Primate (Fujian Maternity and Child Health Hospital), No. 19 Jinjishan Road, Jin’an District, Fuzhou, 350013 China
- Medical Research Center, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Maternityand Child Health Hospital, Fujian Medical University, Fuzhou, China
| | - Zhanxiang Wang
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
- School of Medicine, Xiamen University, Xiamen, China
- National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen, China
- Department of Neurosurgery and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
| | - Qilin Ma
- Department of Neurology and Department of Neuroscience, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, 55 Zhenhai Road, Xiamen, 361003 China
- Fujian Key Laboratory of Brain Tumors Diagnosis and Precision Treatment, Xiamen, China
- Xiamen Key Laboratory of Brain Center, Xiamen, China
- Xiamen Medical Quality Control Center for Neurology, Xiamen, China
- Fujian Provincial Clinical Research Center for Brain Diseases, Xiamen, China
- Xiamen Clinical Research Center for Neurological Diseases, Xiamen, China
- School of Medicine, Xiamen University, Xiamen, China
- National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen, China
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16
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Erritzøe-Jervild M, Wenstrup J, Hougaard BH, Kruuse C. Diagnosing cancer-associated ischemic stroke: A systematic review of hematological biomarkers. Int J Stroke 2024:17474930241227385. [PMID: 38192106 DOI: 10.1177/17474930241227385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND AND AIM Patients suffering from cancer are reported to have an increased risk of ischemic stroke (IS). We aimed to identify cancer-associated biomarkers found to differentiate between IS associated with cancer from those not associated with cancer. SUMMARY OF REVIEW We performed a systematic search of PubMed and EMBASE databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The study is reported in PROSPERO (#CRD42022355129). In total, 5563 papers were screened, of which 49 papers were included. Seven biomarkers were identified which had the potential to differentiate between patients who had cancer or stroke or both conditions. D-dimer was the most frequently monitored biomarker, and high levels were significantly associated with cancer-related strokes in (42/44) studies. Fibrinogen was significantly associated with cancer-related strokes in 11/27 studies. A higher level of C-reactive protein, investigated in 19 studies, was associated with cancer-related strokes, but conclusive multivariate analysis was not performed. Finally, the four cancer-associated antigens CA125, CA153, CA199, and carcinoembryonic antigen were only reported on in three to six studies, respectively. These studies all originated from the Guangxi province in China. CA125 was associated with an increased risk of IS in four of six studies. CONCLUSION Increased D-dimer seems associated with cancer-related IS. CRP may also be a candidate as a cancer-associated stroke biomarker, but this requires further verification. Fibrinogen and the more specific cancer biomarkers have not yet been proven helpful for detecting cancer-related strokes.
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Affiliation(s)
- Mai Erritzøe-Jervild
- Department of Neurology, Neurovascular Research Unit, Copenhagen University Hospital-Herlev Gentofte, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Neuroscience Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jonathan Wenstrup
- Department of Neurology, Neurovascular Research Unit, Copenhagen University Hospital-Herlev Gentofte, Copenhagen, Denmark
- Emergency Medical Services, Copenhagen, Denmark
- Emergency Medical Services, Region Zealand, Denmark
| | | | - Christina Kruuse
- Department of Neurology, Neurovascular Research Unit, Copenhagen University Hospital-Herlev Gentofte, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Neuroscience Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Sakurai R, Gon Y, Shimada Y, Okazaki S, Todo K, Sasaki T, Mochizuki H. Association between the controlling nutritional status score and outcomes in ischemic stroke patients with active cancer. J Clin Neurosci 2024; 120:170-174. [PMID: 38245980 DOI: 10.1016/j.jocn.2024.01.011] [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: 11/08/2023] [Revised: 12/20/2023] [Accepted: 01/08/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND The effect of nutritional status on survival in ischemic stroke patients with active cancer remains unclear. METHODS This study retrospectively evaluated ischemic stroke patients with active cancer admitted to a university hospital in Japan between 2006 and 2016. Patients were followed for 2 years after stroke. The controlling nutritional status (CONUT) score was used to classify undernutrition degree into 4 groups: normal, light, moderate, and severe. Survival rates were compared using the Kaplan-Meier method. Hazard ratio (HR) and 95 % confidence intervals (CIs) for mortality were calculated using Cox regression models. RESULTS A total of 158 patients (31 % women; median age: 71 years) were analyzed. Of these, 47 % had distant metastasis. The median (interquartile range) National Institute of Health Stroke Scale and CONUT scores were 4 (1-10) and 5 (3-7), respectively. Kaplan-Meier curve indicated that patients with poorer nutritional status had worse outcomes (overall log-rank test, p < 0.001). The univariable Cox regression analysis showed that the HR (95 % CI) for the light, moderate, and severe groups were 1.14 (0.45-2.86), 3.01 (1.27-7.12), and 2.94 (1.10-7.84), respectively. This statistical significance did not persist after adjustment for potential confounders (HR [95 % CI] for the light, moderate, and severe groups were 0.95 [0.36-2.49], 1.56 [0.57-4.28], and 1.34 [0.37-4.92], respectively). Past stroke, distant metastasis, and plasma D-dimer levels on admission were independent predictors of prognosis. CONCLUSIONS This single-center, retrospective study suggests that nutritional status serves as a prognostic indicator for ischemic stroke patients with active cancer. However, the effect is not statistically independent.
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Affiliation(s)
- Rei Sakurai
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasufumi Gon
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Yuki Shimada
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
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Magami S, Yoshida K, Nakao Y, Oishi H, Yamamoto T. A Single-Center Experience of Mechanical Thrombectomy for Cancer-Associated Ischemic Stroke. JOURNAL OF NEUROENDOVASCULAR THERAPY 2024; 18:37-46. [PMID: 38384394 PMCID: PMC10878738 DOI: 10.5797/jnet.oa.2023-0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/20/2023] [Indexed: 02/23/2024]
Abstract
Objectives Cancer-associated ischemic stroke tends to extend over multiple vascular territories and develops under poor general conditions. Owing to the rarity of such cases and poor prognoses, no comprehensive studies on mechanical thrombectomy for cancer-associated ischemic stroke have been reported in Japan. The present study investigated the radiological and clinical characteristics of mechanical thrombectomy in patients with cancer-associated ischemic stroke at our institution. Methods We retrospectively reviewed 108 patients who underwent mechanical thrombectomy for large cerebral artery occlusion between January 1, 2021, and October 31, 2022, at our institution. The characteristics of mechanical thrombectomy in the cancer-associated ischemic stroke group were compared with those in the control group. Results Of the 108 patients (112 procedures), seven patients (eight procedures) with clinically diagnosed cancer-associated ischemic stroke underwent mechanical thrombectomy. Of the eight procedures, six were performed during hospitalization. In contrast, only 10 of 104 procedures were performed in the control group. The in-hospital onset rate was higher in the cancer-associated ischemic stroke group (75.0%) compared to that in the controls (9.6%); p <0.001. The puncture-to-reperfusion time was significantly longer in the cancer-associated ischemic stroke group in comparison to that in the controls with a median interquartile range of 69 minutes (60.0-82.0 minutes) and 59.5 minutes (44.5-69.3 minutes), respectively (p <0.01). However, the rates of successful recanalization defined as thrombolysis in cerebral infarction ≥2b were not significantly different between the cancer-associated ischemic stroke group and controls with values of 62.5% and 79.8%, respectively (p = 0.250). Of the eight cases in the cancer-associated ischemic stroke group, only one (12.5%) had a good outcome on a modified Rankin Scale score of 0 to 2 at discharge, in contrast to 23 of the 104 (23.1%) cases in the controls (p = 0.523). Histopathological examination of six retrieved thrombi in the cancer-associated stroke group using hematoxylin and eosin staining revealed that only one case showed an erythrocyte-dominant thrombus while five displayed a fibrinoplatelet-dominant component. Conversely, 65 of 92 retrieved thrombi in the control group were erythrocyte dominant. Cancer was pathologically diagnosed in four of seven patients, all of which were adenocarcinomas. Conclusion Cancer-associated ischemic stroke tends to occur during hospitalization. Coagulation disorders associated with cancer, especially adenocarcinoma, may be related to the formation of thrombi with fibrinoplatelet-dominant components, leading to ischemic stroke. The procedural time for mechanical thrombectomy in cancer-associated ischemic stroke tends to be longer.
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Affiliation(s)
- Shunsuke Magami
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Kouhei Yoshida
- Department of Neurosurgery, Juntendo University, Tokyo, Japan
| | - Yasuaki Nakao
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Hidenori Oishi
- Department of Neurosurgery, Juntendo University, Tokyo, Japan
- Department of Neuroendovascular Therapy, Juntendo University, Tokyo, Japan
| | - Takuji Yamamoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
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Yan H, Sasaki T, Gon Y, Nishiyama K, Kanki H, Mochizuki H. Driver gene KRAS aggravates cancer-associated stroke outcomes. Thromb Res 2024; 233:55-68. [PMID: 38029547 DOI: 10.1016/j.thromres.2023.11.015] [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: 06/01/2023] [Revised: 11/04/2023] [Accepted: 11/14/2023] [Indexed: 12/01/2023]
Abstract
The incidence of cancer-associated stroke has increased with the prolonged survival times of cancer patients. Recent genetic studies have led to progress in cancer therapeutics, but relationships between oncogenic mutations and stroke remain elusive. Here, we focused on the driver gene KRAS, which is the predominant RAS isoform mutated in multiple cancer types, in cancer associated stroke study. KRASG13D/- and parental human colorectal carcinoma HCT116 cells were inoculated into mice that were then subjected to a photochemically-induced thrombosis model to establish ischemic stroke. We found that cancer inoculation exacerbated neurological deficits after stroke. Moreover, mice inoculated with KRASG13D/- cells showed worse neurological deficits after stroke compared with mice inoculated with parental cells. Stroke promoted tumor growth, and the KRASG13D/- allele enhanced this growth. Brain RNA sequencing analysis and serum ELISA showed that chemokines and cytokines mediating pro-inflammatory responses were upregulated in mice inoculated with KRASG13D/- cells compared with those inoculated with parental cells. STAT3 phosphorylation was promoted following ischemic stroke in the KRASG13D/- group compared with in the parental group, and STAT3 inhibition significantly ameliorated stroke outcomes by mitigating microglia/macrophage polarization. Finally, we compared the prognosis and mortality of colorectal cancer patients with or without stroke onset between 1 January 2007 and 31 December 2020 using a hospital-based cancer registry and found that colorectal cancer patients with stroke onset within 3 months after cancer diagnosis had a worse prognosis. Our work suggests an interplay between KRAS and ischemic stroke that may offer insight into future treatments for cancer-associated stroke.
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Affiliation(s)
- Haomin Yan
- Department of Neurology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka 565-0871, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka 565-0871, Japan; Department of Neurotherapeutics, Graduate School of Medicine, Osaka University, Osaka, Japan.
| | - Yasufumi Gon
- Department of Neurology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka 565-0871, Japan
| | - Kumiko Nishiyama
- Department of Neurology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka 565-0871, Japan
| | - Hideaki Kanki
- Department of Neurology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka 565-0871, Japan
| | - Hideki Mochizuki
- Department of Neurology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka 565-0871, Japan
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Mishra RK, Chavda VK, Moscote-Salazar LR, Atallah O, Das S, Janjua T, Maurya VP, Agrawal A. Systematic review and meta-analysis of studies comparing baseline D-dimer level in stroke patients with or without cancer: Strength of current evidence. J Neurosci Rural Pract 2024; 15:16-28. [PMID: 38476438 PMCID: PMC10927037 DOI: 10.25259/jnrp_379_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/06/2023] [Indexed: 03/14/2024] Open
Abstract
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.
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Affiliation(s)
- Rakesh Kumar Mishra
- Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Vishal K. Chavda
- Department of Pathology, Stanford University School of Medicine, Stanford University Medical Center, CA-USA
| | | | - Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Saikat Das
- Department of Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Tariq Janjua
- Department of Neurology, Regions Hospital, Saint Paul, Minnesota, United States
| | - Ved Prakash Maurya
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amit Agrawal
- Department of Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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21
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Kanno M, Yunokawa M, Fusegi A, Abe A, Nomura H, Kanao H. Cerebral infarction caused by Trousseau syndrome associated with cervical cancer. J Gynecol Oncol 2024; 35:35.e41. [PMID: 38178703 DOI: 10.3802/jgo.2024.35.e41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/11/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024] Open
Abstract
OBJECTIVE The combination of cancer and hypercoagulable states is often called Trousseau syndrome. In particular, cerebral infarction caused by Trousseau syndrome is reported to have a poor prognosis. In gynecology, there are many reports of ovarian cancer and a few of uterine cancer. Since there has been no comprehensive report of Trousseau syndrome in cervical cancer, we aimed to summarize Trousseau syndrome in cervical cancer. METHODS Cerebral infarction caused by cancer-related arterial thrombosis was defined as Trousseau syndrome. Patients with cervical cancer diagnosed at our hospital between January 2014 and December 2021 were retrospectively reviewed using the hospital's medical records. RESULTS A total of 1,432 patients were included in the study. Trousseau syndrome occurred in 6 patients (0.4%). The mean age of patients with Trousseau syndrome was 63 years (range: 53-78 years). Of the 6 patients who developed Trousseau's syndrome, 4 patients had it before or during initial treatment, and 2 during recurrent/relapsed disease treatment. The 4 patients who developed the syndrome before or during initial treatment had advanced disease: 1 in stage IIIC and 3 in stage IVB. In all cases, the disease was associated with progressive distant metastasis. The median survival time from the onset of Trousseau syndrome was 1 month (range: 0-6 months). CONCLUSION Cervical cancer causes Trousseau syndrome in cases of advanced disease with a short time between the onset of the syndrome and mortality.
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Affiliation(s)
- Motoko Kanno
- Department of Gynecologic Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Mayu Yunokawa
- Department of Gynecologic Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
- Department of Medical Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Atsushi Fusegi
- Department of Gynecologic Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akiko Abe
- Department of Gynecologic Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hidetaka Nomura
- Department of Gynecologic Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiroyuki Kanao
- Department of Gynecologic Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
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22
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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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Shen R, Wang J, Wang R, Tian Y, Guo P, Shen S, Liu D, Zou T. The Role of Cancer in the Risk of Cardiovascular and All-Cause Mortality: A Nationwide Prospective Cohort Study. Int J Public Health 2023; 68:1606088. [PMID: 37927387 PMCID: PMC10620309 DOI: 10.3389/ijph.2023.1606088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023] Open
Abstract
Objectives: Evidence on cardiovascular-related and all-cause mortality risks in a wide range of cancer survivors is scarce but needed to inform prevention and management. Methods: We performed a nationwide prospective cohort study using information from the Continuous National Health and Nutrition Examination Survey (NHANES) in the United States and the linked mortality follow-up files, available for public access. A propensity score-matched analysis with a 1:1 ratio was conducted to reduce the baseline differences between participants with and without cancer. The relationship between cancer status and the cardiovascular-related and all-cause mortality risk was examined using weighted Cox proportional hazards regression. Independent stratification analysis and cancer-specific analyses were also performed. Results: The study sample included 44,342 participants, aged 20-85, interviewed between 1999 and 2018. Of these, 4,149 participants had cancer. All-cause death occurred in 6,655 participants, of whom 2,053 died from cardiovascular causes. Propensity-score matching identified 4,149 matched pairs of patients. A fully adjusted Cox proportional hazards regression showed that cancer was linked to an elevated risk of cardiovascular-related and all-cause mortality both before and after propensity score matching. Stratification analysis and cancer-specific analyses confirmed robustness of results. Conclusion: Our study confirmed that cancer was strongly linked to cardiovascular-related and all-cause mortality, even after adjusting for other factors that could impact a risk, including the American Heart Association (AHA)'s Life's Simple 7 cardiovascular health score, age, sex, ethnicity, marital status, income, and education level.
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Affiliation(s)
- Ruihuan Shen
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Jia Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Peking University Fifth School of Clinical Medicine, Beijing, China
| | - Rui Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Yuqing Tian
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Peiyao Guo
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Peking University Fifth School of Clinical Medicine, Beijing, China
| | - Shuhui Shen
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Donghao Liu
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Peking University Fifth School of Clinical Medicine, Beijing, China
| | - Tong Zou
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
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Kwon JY, Park K, Song JM, Pyeon SY, Lee SH, Chung YS, Lee JM. Risk Factors and Prognosis of Stroke in Gynecologic Cancer Patients. Cancers (Basel) 2023; 15:4895. [PMID: 37835590 PMCID: PMC10572068 DOI: 10.3390/cancers15194895] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/03/2023] [Accepted: 10/08/2023] [Indexed: 10/15/2023] Open
Abstract
Increased life expectancy and cancer prevalence rates expose patients to a higher risk of developing other comorbidities such as stroke. This study aimed to evaluate the risk factors for and prognosis of stroke in patients with gynecological cancers. A single-center retrospective cohort study was conducted on patients with cervical, endometrial, and epithelial ovarian cancers. Patients were classified into three groups based on the period of stroke onset: at least one year before cancer diagnosis, within one year before cancer diagnosis to six months after the last treatment date, and six months after the last treatment date. Among the 644 patients, stroke occurred in 54 (8.4%). In univariate analysis, stroke was significantly associated with overall survival. In contrast, in multivariate analysis, stroke was significantly associated with age and hypertension, but not with overall survival. Age, pulmonary thromboembolism/deep vein thrombosis, histological grade, and tumor stage were significantly associated with overall survival. Therefore, it is important to establish an appropriate examination and treatment plan for patients with gynecologic cancers using a multidisciplinary approach that incorporates the patient's age, medical condition, and tumor characteristics rather than excessively considering the adverse effects of stroke on cancer prognosis.
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Affiliation(s)
- Ji Young Kwon
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea; (J.Y.K.); (K.P.); (J.M.S.); (S.Y.P.); (Y.S.C.)
- Department of Medicine, Graduate School, Kyung Hee University, Seoul 02447, Republic of Korea
| | - Kena Park
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea; (J.Y.K.); (K.P.); (J.M.S.); (S.Y.P.); (Y.S.C.)
- Department of Medicine, Graduate School, Kyung Hee University, Seoul 02447, Republic of Korea
| | - Jeong Min Song
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea; (J.Y.K.); (K.P.); (J.M.S.); (S.Y.P.); (Y.S.C.)
- Department of Medicine, Graduate School, Kyung Hee University, Seoul 02447, Republic of Korea
| | - Seung Yeon Pyeon
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea; (J.Y.K.); (K.P.); (J.M.S.); (S.Y.P.); (Y.S.C.)
| | - Seon Hwa Lee
- Medical Big Data Research Center, Research Institute of Clinical Medicine, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea;
| | - Young Shin Chung
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea; (J.Y.K.); (K.P.); (J.M.S.); (S.Y.P.); (Y.S.C.)
| | - Jong-Min Lee
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Seoul 05278, Republic of Korea; (J.Y.K.); (K.P.); (J.M.S.); (S.Y.P.); (Y.S.C.)
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Hayakawa M. Cancer-Associated Stroke and Acute Endovascular Reperfusion Therapy. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:272-280. [PMID: 38025257 PMCID: PMC10657734 DOI: 10.5797/jnet.ra.2023-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/19/2023] [Indexed: 12/01/2023]
Abstract
Since stroke is often associated with cancer, acute stroke patients with cancer undergoing endovascular therapy (EVT) are not uncommon. Reportedly, the proportion of such cases is approximately 6%-7% of all stroke EVT cases. Ischemic stroke in patients with active cancer (cancer-associated stroke) includes not only strokes caused by cancer-related hypercoagulability but also coincident strokes due to common etiologies, strokes associated with tumor emboli, direct tumor invasion of blood vessels, and strokes associated with cancer therapy. Stroke caused by cancer-related hypercoagulability itself encompasses various entities, including paradoxical embolism, stroke due to nonbacterial thrombotic endocarditis, and in situ arterial occlusion due to disseminated intravascular coagulation or thrombotic microangiopathy. Thus, diverse mechanisms contribute to cancer-associated stroke, emphasizing the need to consider individualized treatment strategies for acute cases involving large vessel occlusion. Observational studies have shown that EVT for cancer-associated stroke results in poorer clinical outcomes, but with comparable rates of successful reperfusion and symptomatic intracranial hemorrhage when compared with stroke patients without cancer. This suggests that denying patients EVT solely on the basis of comorbid active cancer is inappropriate, and decision-making should be shared with the patients and their families, preferably through a multidisciplinary team approach. Thrombi retrieved from patients with stroke caused by cancer-related hypercoagulability have unique characteristics, being predominantly platelet rich and difficult to retrieve. Preprocedural imaging and serum biomarkers, including the hyperdense vessel sign on non-contrast CT, susceptibility vessel sign on T2* or susceptibility-weighted MRI, three-territory sign on MRI, and D-dimer levels, are valuable in evaluating the stroke subtype and thrombus features. Thrombectomy techniques, such as contact aspiration and stent retriever monotherapy, have shown varying degrees of effectiveness for stroke caused by cancer-related hypercoagulability, warranting further study. After reperfusion therapy, appropriate treatment for the prevention of stroke recurrence should be initiated, considering the specific stroke subtypes. In conclusion, cancer-associated stroke encompasses diverse subtypes, and thrombi associated with stroke caused by cancer-related hypercoagulability present various challenges for thrombectomy. Individualized treatment approaches based on underlying mechanisms are essential for improving outcomes in acute stroke patients with active cancer. Optimization of preprocedural diagnosis, EVT techniques, and secondary prevention of stroke caused by cancer-related hypercoagulability will lead to better management of these patients and enhance their quality of life.
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Affiliation(s)
- Mikito Hayakawa
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
- Department of Neurology, Institute of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Kim K, Jung H, Di Giovanna E, Jun TJ, Kim YH. Increased risk of ischemic stroke associated with elevated gamma-glutamyl transferase level in adult cancer survivors: a population-based cohort study. Sci Rep 2023; 13:16837. [PMID: 37803039 PMCID: PMC10558526 DOI: 10.1038/s41598-023-43839-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/28/2023] [Indexed: 10/08/2023] Open
Abstract
Adult cancer survivors may have an increased risk of developing ischemic stroke, potentially influenced by cancer treatment-related factors and shared risk factors with stroke. However, the association between gamma-glutamyl transferase (GGT) levels and the risk of ischemic stroke in this population remains understudied. Therefore, our study aimed to examine the relationship between GGT levels and the risk of ischemic stroke using a population-based cohort of adult cancer survivors. A population-based cohort of adult cancer survivors was derived from the National Health Insurance Service-Health Screening Cohort between 2003 and 2005 who survived after diagnosis of primary cancer and participated in the biennial national health screening program between 2009 and 2010. Cox proportional hazards model adjusted for sociodemographic factors, health status and behavior, and clinical characteristics was used to investigate the association between GGT level and ischemic stroke in adult cancer survivors. Among 3095 adult cancer survivors, 80 (2.58%) incident cases of ischemic stroke occurred over a mean follow-up of 8.2 years. Compared to the lowest GGT quartile, the hazard ratios (HRs) for ischemic stroke were 1.56 (95% CI 0.75-3.26), 2.36 (95% CI 1.12-4.99), and 2.40 (95% CI 1.05-5.46) for the second, third, and fourth sex-specific quartiles, respectively (Ptrend = 0.013). No significant effect modification was observed by sex, insurance premium, and alcohol consumption. High GGT level is associated with an increased risk of ischemic stroke in adult cancer survivors independent of sex, insurance premium, and alcohol consumption.
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Affiliation(s)
- Kyuwoong Kim
- National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Hyeyun Jung
- The Institute of Clinical Sciences, Imperial College London, London, UK
| | - Edvige Di Giovanna
- Department of Diagnostic and Interventional Radiology, Ammerland-Klinik, Westerstede, Lower Saxony, Germany
| | - Tae Joon Jun
- Big Data Research Center, Asan Institute for Life Science, Asan Medical Center, Seoul, Republic of Korea.
| | - Young-Hak Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Ajabnoor AM, Parisi R, Zghebi SS, Ashcroft DM, Faivre‐Finn C, Morris C, Mamas MA, Kontopantelis E. Common Cancer Types and Risk of Stroke and Bleeding in Patients With Nonvalvular Atrial Fibrillation: A Population-Based Study in England. J Am Heart Assoc 2023; 12:e029423. [PMID: 37750567 PMCID: PMC10727261 DOI: 10.1161/jaha.123.029423] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/08/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND The association between cancer and stroke or bleeding outcomes in atrial fibrillation is unclear. We sought to examine how certain types of cancer influence the balance between stroke and bleeding risk in patients with nonvalvular atrial fibrillation (NVAF). METHODS AND RESULTS We estimated stroke and bleeding risk among adult patients with NVAF and certain types of cancer (breast, prostate, colorectal, lung, and hematological cancer) from 2009 to 2019 based on data from the UK Clinical Practice Research Datalink GOLD and Aurum databases. The control group included patients with NVAF only. Of 177 065 patients with NVAF, 11379 (6.4%) had cancer (1691 breast, 3955 prostate, 1666 colorectal, 2491 hematological, and 1576 lung). Compared with patients without cancer, stroke risk was higher in patients with breast cancer (adjusted hazard ratio [aHR], 1.20 [95% CI, 1.07-1.35) and with prostate cancer (aHR, 1.11 [95% CI, 1.01-1.12) if diagnosed within 6 months before NVAF. The risk of bleeding was increased in subjects with hematological cancer (aHR, 1.55 [95% CI, 1.40-1.71]), lung cancer (aHR, 1.49 [95% CI, 1.25, 1.77]), prostate cancer (aHR, 1.38 [95% CI, 1.28-1.49]), and colorectal cancer (aHR, 1.36 [95% CI, 1.21-1.53]), but not for subjects with breast cancer. The more recent the cancer diagnosis before NVAF diagnosis (within 6 months), the higher the risk of bleeding. CONCLUSIONS Breast and prostate cancer are associated with increased stroke risk, whereas in some cancer types, the risk of bleeding seemed to exceed stroke risk. In these patients, prescribing of oral anticoagulant should be carefully evaluated to balance bleeding and stroke risk.
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Affiliation(s)
- Alyaa M. Ajabnoor
- Department of Pharmacy Practice, Faculty of PharmacyKing Abdulaziz UniversityJeddahSaudi Arabia
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC)University of ManchesterManchesterUnited Kingdom
| | - Rosa Parisi
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC)University of ManchesterManchesterUnited Kingdom
| | - Salwa S. Zghebi
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC)University of ManchesterManchesterUnited Kingdom
| | - Darren M. Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUnited Kingdom
- National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Research Collaboration (PSRC)University of ManchesterManchesterUnited Kingdom
| | - Corinne Faivre‐Finn
- The Christie NHS Foundation Trust and The University of ManchesterManchesterUnited Kingdom
| | - Charlotte Morris
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC)University of ManchesterManchesterUnited Kingdom
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health SciencesKeele UniversityKeeleUnited Kingdom
| | - Evangelos Kontopantelis
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC)University of ManchesterManchesterUnited Kingdom
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Beyeler M, Castigliego P, Baumann J, Ziegler V, Kielkopf M, Mueller M, Bauer-Gambelli SA, Mujanovic A, Meinel TR, Horvath T, Fischer U, Kaesmacher J, Heldner MR, Seiffge D, Arnold M, Pabst T, Berger MD, Navi BB, Jung S, Bücke P. Transient ischemic attacks in patients with active and occult cancer. Front Neurol 2023; 14:1268131. [PMID: 37840935 PMCID: PMC10568457 DOI: 10.3389/fneur.2023.1268131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/05/2023] [Indexed: 10/17/2023] Open
Abstract
Background and aim Paraneoplastic coagulopathy can present as stroke and is associated with specific biomarker changes. Identifying paraneoplastic coagulopathy can help guide secondary prevention in stroke patients, and early cancer detection might improve outcomes. However, unlike ischemic stroke, it remains unclear whether paraneoplastic coagulopathy is associated with transient ischemic attacks (TIA). This study assessed the presence of cancer-related biomarkers in TIA patients and evaluated long-term mortality rates in patients with and without active cancer. Methods Active cancer was retrospectively identified in consecutive TIA patients treated at a comprehensive stroke center between 2015 and 2019. An association between the presence of cancer and cancer-related biomarkers was assessed using multivariable logistic regression. Long-term mortality after TIA was analyzed using multivariable Cox regression. Results Among 1436 TIA patients, 72 had active cancer (5%), of which 17 were occult (1.2%). Cancer-related TIA was associated with male gender (adjusted odds ratio [aOR] 2.29, 95% CI 1.12-4.68), history of smoking (aOR 2.77, 95% CI 1.34-5.7), elevated D-dimer (aOR 1.77, 95% CI 1.26-2.49), lactate dehydrogenase (aOR 1.003, 95% CI 1.00-1.005), lower leukocyte count (aOR 1.20, 95% CI 1.04-1.38), and lower hemoglobin (aOR 1.02, 95% CI 1.00-1.04). Long-term mortality was associated with both active cancer (adjusted hazard ratios [aHR] 2.47, 95% CI 1.58-3.88) and occult cancer (aHR 3.08, 95% CI 1.30-7.32). Conclusion Cancer-related TIA is not uncommon. Biomarkers known to be associated with cancer-related stroke also seem to be present in TIA patients. Early identification would enable targeted treatment strategies and could improve outcomes in this patient population.
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Affiliation(s)
- Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Pasquale Castigliego
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joel Baumann
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Victor Ziegler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Kielkopf
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Madlaine Mueller
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan A. Bauer-Gambelli
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adnan Mujanovic
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Raphael Meinel
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Horvath
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Neurology Department, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Martin D. Berger
- Department of Medical Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Babak B. Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, United States
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Kanki H, Matsumoto H, Togami Y, Okuzaki D, Ogura H, Sasaki T, Mochizuki H. Importance of microRNAs by mRNA-microRNA integration analysis in acute ischemic stroke patients. J Stroke Cerebrovasc Dis 2023; 32:107277. [PMID: 37562178 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 08/12/2023] Open
Abstract
OBJECTS The roles of mRNA and microRNA (miRNA) are well known in many diseases, including ischemic stroke; thus, integration analysis using mRNA and miRNA is important to elucidate pathogenesis. However, their contribution, especially that of miRNA-targeted mRNA, to the severity of acute ischemic stroke remains unclear. Therefore, we examined mRNA and miRNA integration analysis targeted for acute ischemic stroke to clarify the pathway related to acute stroke severity. MATERIAL AND METHODS We performed Ingenuity Pathway Analysis (IPA) using RNA extracted from the whole blood of four healthy controls, six minor acute ischemic stroke patients (MS; National Institutes of Health Stroke Scale [NIHSS] < 8), and six severe acute ischemic stroke patients (SS; NIHSS ≥ 8) on admission. mRNA and miRNA were measured using RNA sequencing and RNA expression variation; canonical pathway analysis (CPA) and upstream regulator analyses were performed. RESULTS Acute ischemic stroke patients demonstrated different RNA expressions to healthy controls. Compared to MS patients, in the SS patients, 1222 mRNA, 96 miRNA, and 935 miRNA-targeted mRNA expressions were identified among differentially expressed RNA expressions (p<0.05, |log2 fold change| >1.1). CPA by IPA using mRNAs or miRNA-targeted mRNAs showed that macrophage-stimulating protein (MSP)-recepteur d'origine nantais (RON) signaling was mostly activated in SS patients compared to in MS patients. In addition, upstream regulator analysis in IPA showed that most mRNAs located upstream are miRNAs. CONCLUSIONS In severe acute stroke, integration of mRNA and microRNA analysis showed activated MSP-RON signaling in macrophages, and multiple miRNAs comprehensively controlled the overall pathophysiology of stroke.
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Affiliation(s)
- Hideaki Kanki
- Department of Neurology, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Hisatake Matsumoto
- Department of Traumatology and Acute Critical Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Yuki Togami
- Department of Traumatology and Acute Critical Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Daisuke Okuzaki
- Genome Information Research Center, Research Institute for Microbial Diseases, Osaka University, Osaka 565-0871, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan; Department of Neurotherapeutics, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan.
| | - Hideki Mochizuki
- Department of Neurology, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
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Lee KP, Huang HC, Tsai JY, Hsu LC. Effects of cancer on stroke recurrence and mortality: A single-center retrospective cohort study. eNeurologicalSci 2023; 32:100474. [PMID: 37522033 PMCID: PMC10374457 DOI: 10.1016/j.ensci.2023.100474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 08/01/2023] Open
Abstract
Background Whether patients with stroke and cancer have specific characteristics remains controversial. In addition, research regarding the effects of individual cancer types on stroke outcomes remains scarce. This study investigated the mortality and stroke recurrence rates in patients with stroke and concomitant cancer and evaluated outcome predictors. Methods This study retrospectively enrolled 2610 patients in the Taipei Veterans General Hospital Stroke Registry registered from January 2019 to December 2020. A total of 1868 patients were included after excluding those without acute ischemic stroke or hospitalization. The patients were then categorized into the following diagnostic groups: cancer-associated stroke (CAS), stroke and inactive cancer, and stroke without cancer. The discharge mortality rate, 1-year mortality rate, and 1-year stroke recurrence rate were compared. Multiple clinical characteristics and comorbidities-age, sex, stroke severity, coagulopathy, common vascular risk factors, and acute stroke treatment-were also assessed. Results A total of 302 (16.2%) patients had concomitant cancer; 39 (2.1%) patients were classified as having CAS and 263 (14.1%) as having stroke with inactive cancer. The baseline characteristics, stroke severity, and type of acute reperfusion therapy were similar among the three groups. However, the stroke recurrence and mortality rates were much higher in the patients with CAS in both short-term and long-term follow-up. The 30-day and 1-year mortality rates for the CAS, inactive cancer, and no cancer groups were 17.9%, 12.5%, and 4.7%, (p < 0.001) and 51.3%, 33.8%, and 12.4%, (p < 0.001) respectively. Conclusion Patients with stroke and active cancer had similar stroke severity. However, the 1-year mortality and stroke recurrence rates were higher in these patients than in patients with inactive cancer or the control group.
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Affiliation(s)
- Kang-Po Lee
- Department of Neurology, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Hui-Chi Huang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jui-Yao Tsai
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li-Chi Hsu
- Division of Cerebrovascular Diseases, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
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Vaz CG, Rodrigues J, Pereira D, Matos I, Oliveira C, Bento MJ, Magalhães R, Correia M, Maia LF. The crosstalk between Stroke and Cancer: Incidence of cancer after a first-ever cerebrovascular event in a population-based study. Eur Stroke J 2023; 8:792-801. [PMID: 37317526 PMCID: PMC10472965 DOI: 10.1177/23969873231181628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/26/2023] [Indexed: 06/16/2023] Open
Abstract
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.
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Affiliation(s)
- Catarina Guedes Vaz
- Serviço de Neurologia, Hospital Santo António – Centro Hospitalar Universitário de Santo António (HSA-CHUdSA), Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar – Universidade do Porto (ICBAS-UP), Porto, Portugal
| | - Jéssica Rodrigues
- Grupo de Epidemiologia do Cancro, Centro de Investigação do Instituto Português de Oncologia do Porto, Instituto Português de Oncologia do Porto, Porto, Portugal
| | - Diogo Pereira
- Serviço de Neurologia, Hospital Santo António – Centro Hospitalar Universitário de Santo António (HSA-CHUdSA), Porto, Portugal
| | - Ilda Matos
- Serviço de Neurologia, Unidade Local de Saúde do Nordeste – Mirandela, Mirandela, Portugal
| | - Carla Oliveira
- i3S – Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Ipatimup – Institute of Molecular Pathology and Immunology of the University of Porto, Porto, Portugal
| | - Maria José Bento
- Instituto de Ciências Biomédicas Abel Salazar – Universidade do Porto (ICBAS-UP), Porto, Portugal
- Grupo de Epidemiologia do Cancro, Centro de Investigação do Instituto Português de Oncologia do Porto, Instituto Português de Oncologia do Porto, Porto, Portugal
| | - Rui Magalhães
- Instituto de Ciências Biomédicas Abel Salazar – Universidade do Porto (ICBAS-UP), Porto, Portugal
| | - Manuel Correia
- Serviço de Neurologia, Hospital Santo António – Centro Hospitalar Universitário de Santo António (HSA-CHUdSA), Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar – Universidade do Porto (ICBAS-UP), Porto, Portugal
| | - Luis F Maia
- Serviço de Neurologia, Hospital Santo António – Centro Hospitalar Universitário de Santo António (HSA-CHUdSA), Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar – Universidade do Porto (ICBAS-UP), Porto, Portugal
- i3S – Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
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Dawod J, Abbasi MH, Navi BB, Kasner SE. Quality-of-life, concerns, and treatment priorities in patients with cancer-related ischemic stroke: A prospective survey study. J Stroke Cerebrovasc Dis 2023; 32:107286. [PMID: 37541026 PMCID: PMC10530355 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 08/06/2023] Open
Abstract
OBJECTIVES Comorbid cancer with stroke is a complex situation with multiple factors affecting quality of life (QoL). No specific questionnaire exists to assess current drivers of QoL and future concerns and priorities in patients with cancer-related stroke. METHODS After developing a structured survey instrument, we prospectively interviewed patients with recent ischemic stroke and active cancer to assess views about their condition, factors currently impacting QoL, concerns for the future, and preferences regarding antithrombotic treatment strategy. RESULTS In 2021-2022, at two quaternary-care stroke and cancer centers, we surveyed 50 patients with cancer-related stroke (mean age 70 years, 42% women). Most (87%) had solid cancers with lung, prostate, and breast cancers being the most prevalent. The most frequent adverse feelings were sadness and anxiety about another stroke. Disability from stroke, pain from cancer, and dependency were the items rated to have the highest current effect on patients' QoL and were ranked as the number one effector on QoL in 25%, 23%, and 16% of surveys, respectively; bleeding was ranked the lowest. Cognitive/memory impairment (ranked first in 28% of surveys), dependency on others (ranked first in 18%), and speech disturbance (ranked first in 16%) were the highest ranked future concerns; bleeding and pain were ranked the lowest. When questioned about antithrombotic treatment preferences to prevent further stroke, 50% favored a more aggressive approach with anticoagulant therapy, 16% favored a less aggressive approach with antiplatelet therapy, and 34% were neutral/unsure. CONCLUSIONS Patients with cancer-related stroke reported that stroke disability and cancer pain were their most impactful current issues, while long-term cognitive impairment, functional dependence, and speech disturbance were their most important future concerns. These patients seemed to be more concerned about future stroke than bleeding events and tended to prefer a more aggressive antithrombotic strategy, although considerable variability existed.
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Affiliation(s)
- Judy Dawod
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mohammad Hossein Abbasi
- Department of Neurology, University of Pennsylvania, 3W Gates Bldg, 3400 Spruce St., Philadelphia, PA 19104-4283, United States
| | - Babak B Navi
- Department of Neurology and Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States; Department of Neurology, Memorial Sloan Kettering, New York, NY, United States
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, 3W Gates Bldg, 3400 Spruce St., Philadelphia, PA 19104-4283, United States.
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Atallah O, Chaurasia B. Brain metastasis localized to the same area of infarction: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 6:CASE23325. [PMID: 37581584 PMCID: PMC10555590 DOI: 10.3171/case23325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 07/10/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Ischemic stroke and tumor account for a disproportionate share of deaths and disabilities among the elderly. Patients with a tumor who develop recurrent acute neurological deficits after a stroke can be at risk for tumor-related stroke. In contrast, brain metastases (BM) are common causes of neurological symptoms and are associated with a poor prognosis in patients with both malignancy and ischemic stroke. OBSERVATIONS The authors report a rare case of metastatic melanoma that manifested in the same region as a previous ischemic infarction. A 22-year-old female presented at our emergency department with right hemiparesis and sensory difficulties. Infarction in the left frontoparietal and basal ganglia regions was found on a computed tomography scan of the brain. A decompressive hemicraniectomy was performed urgently. After 16 years, a biopsy taken from her chin revealed malignant melanoma. Hemorrhagic metastasis on the frontal lobe of the brain was detected with magnetic resonance imaging and was histopathologically confirmed upon resection. LESSONS In addition to recurrence, BM may be considered when a person with ischemic stroke and a cancer such as melanoma has new neurological problems in one area that cannot be explained by the stroke.
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Affiliation(s)
- Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany; and
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
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Kim C, Yu H, Kim DK. The Risk of Ischemic and Hemorrhagic Stroke in Head and Neck Cancer: A Longitudinal Cohort Study. Cancers (Basel) 2023; 15:3503. [PMID: 37444613 DOI: 10.3390/cancers15133503] [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: 06/22/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
Several studies have shown that head and neck cancer is associated with an increased risk of stroke incidence. However, investigations of the association between the two diseases based on a matching cohort dataset are still limited. Therefore, we identified the incidence and risk of stroke in patients with head and neck cancer using a nationwide population-based cohort dataset. A total of 5248 individuals without cancer and 1312 with cancer were enrolled from the dataset after a 4:1 propensity score matching. We found that the incidence of overall stroke (per 1000 person years) was 19.29 for those with head and neck cancer, consisting of 17.32 as ischemic type and 2.74 as hemorrhagic type. Additionally, patients with head and neck cancer had a significantly increased risk of overall and ischemic stroke development but not hemorrhagic stroke. Moreover, the risk of stroke development over time was relatively high within the first year after the diagnosis of head and neck cancer. However, in the subgroup analysis, oral cavity cancer survivors showed an increased risk of both ischemic and hemorrhagic strokes. Therefore, our nationwide population-based cohort study suggests that clinicians should closely monitor patients with head and neck cancers for the early detection of stroke.
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Affiliation(s)
- Chulho Kim
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Republic of Korea
- Institute of New Frontier Research, Division of Big Data and Artificial Intelligence, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
| | - Hyunjae Yu
- Institute of New Frontier Research, Division of Big Data and Artificial Intelligence, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
| | - Dong-Kyu Kim
- Institute of New Frontier Research, Division of Big Data and Artificial Intelligence, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea
- Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24253, Republic of Korea
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Takeshima S, Kawate N. Decision-making for intensive rehabilitation in patients with Trousseau syndrome: Insights from a case series. Medicine (Baltimore) 2023; 102:e34097. [PMID: 37390272 PMCID: PMC10313241 DOI: 10.1097/md.0000000000034097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/05/2023] [Indexed: 07/02/2023] Open
Abstract
RATIONALE Patients with Trousseau syndrome, a common complication of advanced cancer, typically have poor survival. For that reason, there is a need to determine the effectiveness of rehabilitation treatment and develop a comprehensive treatment strategy earlier than that in the general stroke population. We investigated the relationship between physical function and its outcome 1 month after the start of intensive rehabilitation treatment in patients with Trousseau syndrome, to obtain insights for determining the indications for intensive rehabilitation in these patients. PATIENT CONCERNS The development of Trousseau syndrome may worsen the performance status (PS), often necessitating a reevaluation of the indications for treatment of the primary cancer. Furthermore, the primary cancer may progress during rehabilitation therapy. DIAGNOSES These patients were diagnosed with Trousseau syndrome. INTERVENTIONS All patients underwent training under the supervision of a therapist for 2 to 3 hours per day, 7 days per week, with a focus on exercise therapy. The functional independence measure (FIM) 1 month after admission to the convalescent rehabilitation ward, modified Rankin scale (mRS) score on admission and on the date of last assessment, and its outcome was examined. OUTCOMES The time from stroke onset to admission to rehabilitation ranged from 22 to 60 days. Primary cancers were lung, bladder, prostate, ovarian, uterine, and unknown primary. Four patients had advanced cancer with distant metastasis. Two patients were discharged to home with independent activities of daily living (ADL) status. Two patients were transferred to palliative care, and 3 patients died. The 2 patients with independent ADL status had a mean motor score of 90 and a mean cognitive score of 30 on FIM, while the other 5 patients had a mean motor score of 29 and a mean cognitive score of 21 at 1 month of admission. Patients with mRS > 3 on admission did not have independent ADL status at 1 month. LESSONS Intensive rehabilitation therapy may be indicated for patients with Trousseau syndrome who are expected to improve physical function after approximately 1 month of rehabilitation. Palliative care should be considered if recovery is inadequate.
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Affiliation(s)
- Shinichi Takeshima
- Department of Rehabilitation Medicine, Showa University School of Medicine, Yokohama, Kanagawa, Japan
| | - Nobuyuki Kawate
- Department of Rehabilitation Medicine, Showa University School of Medicine, Yokohama, Kanagawa, Japan
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Aloizou AM, Palaiodimou L, Aloizou D, Dardiotis E, Gold R, Tsivgoulis G, Krogias C. Acute reperfusion treatment and secondary prevention of cancer-related stroke: comprehensive overview and proposal of clinical algorithm. Ther Adv Neurol Disord 2023; 16:17562864231180717. [PMID: 37342814 PMCID: PMC10278431 DOI: 10.1177/17562864231180717] [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: 02/23/2023] [Accepted: 05/20/2023] [Indexed: 06/23/2023] Open
Abstract
Cancer-related stroke (CRS), referring to ischemic stroke occurring in cancer patients without other clear etiology, represents a clinical challenge, as it is associated with unfavorable clinical outcomes including high rates of recurrence and mortality. There are scarce international recommendations and limited consensus statements on CRS management. For this comprehensive overview, the available studies/reviews/meta-analyses on the use of acute reperfusion and secondary prevention treatments for cancer patients with ischemic stroke, focusing on antithrombotic agents, were collected and summarized. A practical management algorithm was designed per the available data. In short, acute reperfusion in the form of intravenous thrombolysis and mechanical thrombectomy appears to be safe in CRS and can be considered for eligible patients, though the functional outcomes are often poor, and mostly defined by the preexisting condition. Many patients carry indications for anticoagulation, in which case vitamin K antagonists are not preferred, while low-molecular weight heparins remain the treatment of choice; direct oral anticoagulants can be alternatively considered but are contraindicated for gastrointestinal malignancies. For patients without clear anticoagulation indications, no net benefit for anticoagulation compared to aspirin has been shown. Other targeted treatment options should be evaluated in an individualized approach, alongside the appropriate management of conventional cerebrovascular risk factors. Oncological treatment should be swiftly initiated/continued. In conclusion, acute CRS remains a clinical challenge, with many patients suffering recurrent stroke, despite preventive measures. More randomized-controlled clinical trials are urgently needed to pinpoint the most effective management options for this subset of stroke patients.
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Affiliation(s)
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, ‘Attikon’ University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitra Aloizou
- Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
| | - Efthimios Dardiotis
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, ‘Attikon’ University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Christos Krogias
- Department of Neurology, Evangelisches Krankenhaus Herne, Ruhr University Bochum, Bochum, Germany
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Costamagna G, Hottinger A, Milionis H, Lambrou D, Salerno A, Strambo D, Livio F, Navi BB, Michel P. Clinical and Demographic Characteristics, Mechanisms, and Outcomes in Patients With Acute Ischemic Stroke and Newly Diagnosed or Known Active Cancer. Neurology 2023; 100:e2477-e2489. [PMID: 37094994 PMCID: PMC10264053 DOI: 10.1212/wnl.0000000000207341] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/09/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with a new diagnosis of cancer carry an increased risk of acute ischemic stroke (AIS), and this risk varies depending on age, cancer type, stage, and time from diagnosis. Whether patients with AIS with a new diagnosis of neoplasm represent a distinct subset from those with a previously known active malignancy remains unclear. We aimed to estimate the rate of stroke in patients with newly diagnosed cancer (NC) and previously known active cancer (KC) and to compare the demographic and clinical features, stroke mechanisms, and long-term outcomes between groups. METHODS Using 2003-2021 data from the Acute STroke Registry and Analysis of Lausanne registry, we compared patients with KC with patients with NC (cancer identified during AIS hospitalization or within the following 12 months). Patients with inactive and no history of cancer were excluded. Outcomes were the modified Rankin scale (mRS) score at 3 months and mortality and recurrent stroke at 12 months. We used multivariable regression analyses to compare outcomes between groups while adjusting for important prognostic variables. RESULTS Among 6,686 patients with AIS, 362 (5.4%) had active cancer (AC), including 102 (1.5%) with NC. Gastrointestinal and genitourinary cancers were the most frequent cancer types. Among all patients with AC, 152 (42.5%) AISs were classified as cancer related, with nearly half of these cases attributed to hypercoagulability. In multivariable analysis, patients with NC had less prestroke disability (adjusted odds ratio [aOR] 0.62, 95% CI 0.44-0.86) and fewer prior stroke/transient ischemic attack events (aOR 0.43, 95% CI 0.21-0.88) than patients with KC. Three-month mRS scores were similar between cancer groups (aOR 1.27, 95% CI 0.65-2.49) and were predominantly driven by the presence of newly diagnosed brain metastases (aOR 7.22, 95% CI 1.49-43.17) and metastatic cancer (aOR 2.19, 95% CI 1.22-3.97). At 12 months, mortality risk was higher in patients with NC vs patients with KC (hazard ratio [HR] 2.11, 95% CI 1.38-3.21), while recurrent stroke risk was similar between groups (adjusted HR 1.27, 95% CI 0.67-2.43). DISCUSSION In a comprehensive institutional registry spanning nearly 2 decades, 5.4% of patients with AIS had AC, a quarter of which were diagnosed during or within 12 months after the index stroke hospitalization. Patients with NC had less disability and prior cerebrovascular disease, but a higher 1-year risk of subsequent death than patients with KC.
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Affiliation(s)
- Gianluca Costamagna
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Andreas Hottinger
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Haralampos Milionis
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dimitris Lambrou
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexander Salerno
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Davide Strambo
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Françoise Livio
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Babak Benjamin Navi
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Patrik Michel
- From the Stroke Center (G.C., D.L., A.S., D.S., P.M.), Neurology Service, Department of Clinical Neurosciences, L. Lundin & Family Brain Tumor Research Center (A.H.), Services of Neurology and Oncology, and Service of Clinical Pharmacology (F.L.), Lausanne University Hospital and University of Lausanne, Switzerland; Dino Ferrari Centre (G.C.), Department of Pathophysiology and Transplantation (DEPT), University of Milan, Italy; 1st Department of Internal Medicine (H.M.), University of Ioannina, Medical School, Greece; Feil Family Brain and Mind Research Institute and Department of Neurology (B.B.N.), Weill Cornell Medicine; and Department of Neurology (B.B.N.), Memorial Sloan Kettering Cancer Center, New York, NY
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Osteraas ND, Dafer RM. Advances in Management of the Stroke Etiology One-Percenters. Curr Neurol Neurosci Rep 2023; 23:301-325. [PMID: 37247169 PMCID: PMC10225785 DOI: 10.1007/s11910-023-01269-z] [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] [Accepted: 04/13/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE OF REVIEW Uncommon causes of stroke merit specific attention; when clinicians have less common etiologies of stoke in mind, the diagnosis may come more easily. This is key, as optimal management will in many cases differs significantly from "standard" care. RECENT FINDINGS Randomized controlled trials (RCT) on the best medical therapy in the treatment of cervical artery dissection (CeAD) have demonstrated low rates of ischemia with both antiplatelet and vitamin K antagonism. RCT evidence supports the use of anticoagulation with vitamin K antagonism in "high-risk" patients with antiphospholipid antibody syndrome (APLAS), and there is new evidence supporting the utilization of direct oral anticoagulation in malignancy-associated thrombosis. Migraine with aura has been more conclusively linked not only with increased risk of ischemic and hemorrhagic stroke, but also with cardiovascular mortality. Recent literature has surprisingly not provided support the utilization of L-arginine in the treatment of patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS); however, there is evidence at this time that support use of enzyme replacement in patients with Fabry disease. Additional triggers for reversible cerebral vasoconstriction syndrome (RCVS) have been identified, such as capsaicin. Imaging of cerebral blood vessel walls utilizing contrast-enhanced MRA is an emerging modality that may ultimately prove to be very useful in the evaluation of patients with uncommon causes of stroke. A plethora of associations between cerebrovascular disease and COVID-19 have been described. Where pertinent, authors provide additional tips and guidance. Less commonly encountered conditions with updates in diagnosis, and management along with clinical tips are reviewed.
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Affiliation(s)
| | - Rima M Dafer
- Rush University Medical Center, Chicago, IL, USA.
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St., Suite 1118, Chicago, IL, 60612, USA.
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39
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Escasura MIC, Navarro JC. Predictive factors for clinical outcomes in Filipino patients with watershed infarction: A single center study. eNeurologicalSci 2023; 31:100450. [PMID: 36908808 PMCID: PMC9995929 DOI: 10.1016/j.ensci.2023.100450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/12/2023] [Accepted: 02/11/2023] [Indexed: 02/22/2023] Open
Abstract
Background and purpose Watershed infarcts denote ischemic lesions involving the distal territories of two major arteries. For years, hypotheses on its pathophysiological mechanisms have been proposed. Yet, the cause is still widely debated. This study aimed to determine the mechanism of watershed strokes and compare their clinical outcomes to acute ischemic stroke from other causes and predict the factors affecting clinical outcomes in patients with watershed infarcts. Methods This single-center, comparative, six-years retrospective cohort study included patients with a diagnosis of Acute Ischemic Stroke. Patients were classified under watershed group or acute ischemic stroke based on their neuroimaging findings. Stroke mechanisms were determined between groups as well as the factors associated with clinical outcomes in watershed strokes. Results Among the 424 patients included in the study, large artery atherosclerosis was seen in greater frequency in patients with watershed infarcts regardless of the type (EWIs: n = 68, 73% vs IWIs: n = 89, 75%). No differences observed in the clinical outcomes between groups. Multiple variable analysis showed that age, female sex, high NIHSS score and presence of underlying malignancy were associated with clinical outcomes. Conclusion Clinical outcomes between watershed infarcts and acute ischemic strokes were similar. Hemodynamic compromise in the setting of severe stenosis is the underlying mechanism for both types of watershed strokes thus, the goal of treatment is to maintain adequate perfusion. High baseline NIHSS score, increased age, female gender and underlying malignancy were all poor predictors of clinical outcomes in patients with watershed strokes.
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Affiliation(s)
- Marian Irene C. Escasura
- Stroke Service, Institute of Neurological Sciences, St. Luke's Medical Center, Quezon City, Philippines
- Corresponding author.
| | - Jose C. Navarro
- Stroke Service, Institute of Neurological Sciences, St. Luke's Medical Center, Quezon City, Philippines
- Department of Neurology, Jose R Reyes Memorial Medical Center, Manila, City, Philippines
- Department of Neurology and Psychiatry, University of Santo Tomas, Manila, Philippines
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40
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Sun MY, Bhaskar SMM. Bridging the Gap in Cancer-Related Stroke Management: Update on Therapeutic and Preventive Approaches. Int J Mol Sci 2023; 24:ijms24097981. [PMID: 37175686 PMCID: PMC10178058 DOI: 10.3390/ijms24097981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 04/26/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
The underlying aetiopathophysiology of cancer-related strokes and thromboembolisms differs from that of noncancer-related strokes, which makes treating cancer-related strokes and thromboembolisms a distinct clinical challenge. This necessitates the development of novel, individualised diagnostic and treatment strategies. However, limited guidelines are available for the management of cancer-related strokes and the prevention of acute strokes or other thromboembolic events in this patient population. In this article, we present an updated overview of the therapeutic and preventive strategies for strokes in cancer settings. These strategies include acute reperfusion therapy, anticoagulant therapy, antiplatelet therapy, and lifestyle management options. We also outline comprehensive pathways and highlight gaps in the evidence-based clinical management of cancer-related strokes or thromboembolisms. Additionally, future recommendations for the management of strokes in cancer patients are provided.
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Affiliation(s)
- Ming-Yee Sun
- Global Health Neurology Lab, Sydney, NSW 2000, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
- UNSW Medicine and Health, University of New South Wales (UNSW), South Western Sydney Clinical Campuses, Sydney, NSW 2170, Australia
| | - Sonu M M Bhaskar
- Global Health Neurology Lab, Sydney, NSW 2000, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital and South West Sydney Local Health District (SWSLHD), Liverpool, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Stroke and Neurology Research Group, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
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Lun R, Shaw JR, Roy DC, Siegal D, Ramsay T, Chen Y, Dowlatshahi D. Effect modification of age and hypertension on cancer and prevalence of self-reported stroke - A cross-sectional study. Cancer Med 2023. [PMID: 37083306 DOI: 10.1002/cam4.5964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 03/05/2023] [Accepted: 04/05/2023] [Indexed: 04/22/2023] Open
Abstract
The objective of this study was to examine the effect modification of age on the relationship between cancer and prevalence of self-reported stroke. We used cross-sectional data from the 2015-2016 iteration of the Canadian Community Health Survey. A multivariable logistic regression model was used to assess the association between cancer and self-reported stroke. Covariates were assessed for effect modification using the maximum likelihood estimation method. We analyzed 86,809 subjects; the prevalence of self-reported stroke was 1.11%. The odds ratio for the association between cancer and self-reported stroke was 1.26 (95% CI 0.98-1.61) after adjusting for age, sex, dyslipidemia, hypertension, diabetes, heart disease, education, and household income. Age and hypertension were found to be effect modifiers, and the association between cancer and self-reported stroke was stronger in younger adults and in those without hypertension. These results suggest that cancer-associated strokes may have unique underlying mechanisms compared to conventional strokes.
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Affiliation(s)
- Ronda Lun
- Division of Neurology, Department of Medicine, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- University of Ottawa, School of Epidemiology, Ottawa, Ontario, Canada
| | - Joseph R Shaw
- University of Ottawa, School of Epidemiology, Ottawa, Ontario, Canada
- Division of Hematology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Deborah Siegal
- University of Ottawa, School of Epidemiology, Ottawa, Ontario, Canada
- Division of Hematology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Tim Ramsay
- University of Ottawa, School of Epidemiology, Ottawa, Ontario, Canada
| | - Yue Chen
- University of Ottawa, School of Epidemiology, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Division of Neurology, Department of Medicine, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- University of Ottawa, School of Epidemiology, Ottawa, Ontario, Canada
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Waseem A, Rashid S, Rashid K, Khan MA, Khan R, Haque R, Seth P, Raza SS. Insight into the transcription factors regulating Ischemic Stroke and Glioma in Response to Shared Stimuli. Semin Cancer Biol 2023; 92:102-127. [PMID: 37054904 DOI: 10.1016/j.semcancer.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/28/2023] [Accepted: 04/09/2023] [Indexed: 04/15/2023]
Abstract
Cerebral ischemic stroke and glioma are the two leading causes of patient mortality globally. Despite physiological variations, 1 in 10 people who have an ischemic stroke go on to develop brain cancer, most notably gliomas. In addition, glioma treatments have also been shown to increase the risk of ischemic strokes. Stroke occurs more frequently in cancer patients than in the general population, according to traditional literature. Unbelievably, these events share multiple pathways, but the precise mechanism underlying their co-occurrence remains unknown. Transcription factors (TFs), the main components of gene expression programmes, finally determine the fate of cells and homeostasis. Both ischemic stroke and glioma exhibit aberrant expression of a large number of TFs, which are strongly linked to the pathophysiology and progression of both diseases. The precise genomic binding locations of TFs and how TF binding ultimately relates to transcriptional regulation remain elusive despite a strong interest in understanding how TFs regulate gene expression in both stroke and glioma. As a result, the importance of continuing efforts to understand TF-mediated gene regulation is highlighted in this review, along with some of the primary shared events in stroke and glioma.
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Affiliation(s)
- Arshi Waseem
- Laboratory for Stem Cell & Restorative Neurology, Department of Biotechnology, Era's Lucknow Medical College and Hospital, Era University, Sarfarazganj, Lucknow-226003, India
| | - Sumaiya Rashid
- Department of Pharmacology & Toxicology, College of Pharmacy, Prince Sattam Bin Abdulaziz University, P.O. Box 173, Al-Kharj 11942, Saudi Arabia
| | - Khalid Rashid
- Department of Cancer Biology, Vontz Center for Molecular Studies, Cincinnati, OH 45267-0521
| | | | - Rehan Khan
- Chemical Biology Unit, Institute of Nano Science and Technology, Knowledge City,Mohali, Punjab 140306, India
| | - Rizwanul Haque
- Department of Biotechnology, Central University of South Bihar, Gaya -824236, India
| | - Pankaj Seth
- Molecular and Cellular Neuroscience, Neurovirology Section, National Brain Research Centre, Manesar, Haryana-122052, India
| | - Syed Shadab Raza
- Laboratory for Stem Cell & Restorative Neurology, Department of Biotechnology, Era's Lucknow Medical College and Hospital, Era University, Sarfarazganj, Lucknow-226003, India; Department of Stem Cell Biology and Regenerative Medicine, Era's Lucknow Medical College Hospital, Era University, Sarfarazganj, Lucknow-226003, India
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43
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Zuber M. Stroke and cancer. Rev Neurol (Paris) 2023; 179:417-424. [PMID: 37024364 DOI: 10.1016/j.neurol.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 04/08/2023]
Abstract
Association between stroke and cancer is well-established and has led to a growing literature over the past decades. Risk of ischemic and hemorrhagic stroke is increased among patients with newly diagnosed cancer and 5-10% of stroke patients bear an active cancer. All cancers are concerned, but hematological malignancy in childhood and adenocarcinoma from lung, digestive tract and pancreas in adults are most usually identified. Unique stroke mechanisms are dominated by hypercoagulation, a condition that may lead to both arterial and venous cerebral thromboembolism. Direct tumor effects, infections and therapies may also play some active role in stroke happening. Magnetic Resonance Imaging (MRI) is helpful in: i) detecting typical patterns of ischemic stroke in cancer patients (i.e. concomitant strokes in multiple arterial territories); ii) distinguishing spontaneous intracerebral hemorrhage from tumor bleeding. Recent literature suggests that acute treatment using intravenous thrombolysis is safe in non-metastatic cancer patients. First results from endovascular procedures are reassuring, although arterial reobstruction is more frequent than in cancer-free patients. Prognosis is worse in patients with compared to those without cancer and mostly depends upon several predictors such as the initial stroke severity and the presence of metastasis. In the present review, we aim to provide some practical responses to neurologists about the stroke-cancer association, including prevalence, stroke mechanisms, biomarkers indicative for an occult cancer, influence of neoplasia on acute and long-term stroke treatments, and prognosis.
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Affiliation(s)
- M Zuber
- Groupe hospitalier Paris Saint-Joseph, université Paris Cité, Paris, France.
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Peng C, Yang F, Peng L, Zhang C, Lin Z, Chen C, Gao H, He J, Jin Z. Temporal trends and outcomes in acute ischaemic stroke patients with a current or historical diagnosis of cancer. Eur J Neurol 2023; 30:951-962. [PMID: 36704907 DOI: 10.1111/ene.15699] [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: 12/06/2022] [Revised: 12/24/2022] [Accepted: 01/12/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE The aim was to evaluate the temporal trends, characteristics and in-hospital outcomes of patients hospitalized with acute ischaemic stroke (AIS) between those with and without current or historical malignancies. METHODS Adult hospitalizations with a primary diagnosis of AIS were identified from the National Inpatient Sample database 2007-2017. Logistic regression was used to compare the differences in the utilization of AIS interventions and in-hospital outcomes. For further analysis, subgroup analyses were performed stratified by cancer subtypes. RESULTS There were 892,862 hospitalizations due to AIS, of which 108,357 (12.14%) had a concurrent diagnosis of current cancer (3.41%) or historical cancer (8.72%). After adjustment for confounders, patients with current malignancy were more likely to have worse clinical outcomes. The presence of historical cancers was not associated with an increase in poor clinical outcomes. Additionally, AIS patients with current malignancy were less likely to receive intravenous thrombolysis (adjusted odds ratio 0.66, 95% confidence interval 0.63-0.71). Amongst the subgroups of AIS patients treated with intravenous thrombolysis or mechanical thrombectomy, outcomes varied by cancer types. Notably, despite these acute stroke interventions, outcome remains poor in AIS patients with lung cancer. CONCLUSIONS Although AIS patients with malignancy generally have worse in-hospital outcomes versus those without, there were considerable variations in these outcomes according to different cancer types and the use of AIS interventions. Finally, treatment of these AIS patients with a current or historical cancer diagnosis should be individualized.
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Affiliation(s)
- Chi Peng
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Fan Yang
- Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University (Army Medical University) and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Chenxu Zhang
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Zhen Lin
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Chenxin Chen
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Huachen Gao
- Department of Plastic Surgery and Burns, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Jia He
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Zhichao Jin
- Department of Health Statistics, Naval Medical University, Shanghai, China
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Johansen MC. The Future of Ischemic Stroke Diagnosis and a Review of Underrecognized Ischemic Stroke Etiologies. Neurotherapeutics 2023; 20:613-623. [PMID: 37157043 PMCID: PMC10275839 DOI: 10.1007/s13311-023-01383-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 05/10/2023] Open
Abstract
Accurate ischemic stroke etiologic determination and diagnosis form the foundation of excellent cerebrovascular care as from it stems initiation of the appropriate secondary prevention strategy as well as appropriate patient education regarding specific risk factors for that subtype. Recurrent stroke rates are highest among those patients who receive an incorrect initial stroke diagnosis. Patient distrust and patient reported depression are also higher. The cause of the ischemic stroke also informs predicted patient outcomes and the anticipated recovery trajectory. Finally, determining the accurate cause of the ischemic stroke provides the patient the opportunity to enroll in appropriate research studies studying mechanism, or targeting treatment approaches for that particular disease process. Advances in ischemic stroke research, imaging techniques, biomarkers, and the ability to rapidly perform genetic sequencing over the past decade have shown that classifying patients into large etiologic buckets may not always be appropriate and may represent one reason why some patients are labeled as cryptogenic, or for whom an underlying etiology is never found. Aside from the more traditional stroke mechanisms, there is new research emerging regarding clinical findings that are not normative, but the contributions to ischemic stroke are unclear. In this article, we first review the essential steps to accurate ischemic stroke etiologic classification and then transition to a discussion of embolic stroke of undetermined source (ESUS) and other new entities that have been postulated as causal in ischemic stroke (i.e., genetics and subclinical atherosclerosis). We also discuss the limitations that are inherent in the current ischemic stroke diagnostic algorithms and finally review the most recent studies regarding more uncommon diagnoses and the future of stroke diagnostics and classification.
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Akyea RK, Iyen B, Georgiopoulos G, Kai J, Qureshi N, Ntaios G. Cardiovascular outcomes and mortality after incident ischaemic stroke in patients with a recent cancer history. Eur J Intern Med 2023; 109:50-57. [PMID: 36549951 DOI: 10.1016/j.ejim.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 12/07/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Up to 10% of patients with ischaemic stroke have comorbid cancer and stroke in these patients is thought to have a poor short-term prognosis. There is little known about the long-term cardiovascular morbidity and mortality outcomes after incident ischaemic stroke in patients with recent cancer history. OBJECTIVE To assess the risk of subsequent cardiovascular morbidity and mortality outcomes in patients with an incident ischaemic stroke and recent cancer history. METHODS Patients aged ≥18 years with an incident ischaemic stroke between 1998 and 2017, with any diagnosis of cancer within 12 months before the stroke event, and no prior history of serious vascular event were identified from UK Clinical Practice Research Datalink (CPRD GOLD) linked to Hospital Episode Statistics (HES) data. To minimize selection bias, these patients were propensity-score matched with patients with incident ischaemic stroke and no history of cancer. Propensity-score matching was done using covariates such as demographic data, vascular risk factors, comorbid conditions, and prescribed medication. Multivariable models (Competing risks and Cox regression) were used to determine the risk of subsequent major adverse cardiovascular event (MACE) outcomes and all-cause mortality. RESULTS Our cohort included 22,460 patients with a median age of 75 (IQR 64-83) years and a follow-up of 12.3 (IQR 7.2-16.7) years. Recent cancer was identified in 1,149 patients (5.1%) at the time of incident ischaemic stroke. The patients with recent cancer history had a lower risk of composite MACE (sub-distribution hazard ratio (SHR) 0.83 [95% CI: 0.75-0.92]) and recurrent stroke (SHR 0.85 95% CI:0.75-0.96]) and a higher risk of all-cause mortality (hazard ratio 1.67 [95% CI:1.47-1.91]). The risk of coronary heart disease, peripheral vascular disease, heart failure, and CVD-related death outcomes did not differ significantly between the groups. CONCLUSIONS After incident ischaemic stroke, patients with recent cancer history have a lower risk of composite MACE and recurrent stroke outcomes but a higher risk of all-cause mortality when compared with patients without a prior history of cancer.
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Affiliation(s)
- Ralph K Akyea
- Primary Care Stratified Medicine, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
| | - Barbara Iyen
- Primary Care Stratified Medicine, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Georgios Georgiopoulos
- School of Biomedical Engineering and Imaging Sciences, St Thomas Hospital, King's College London, London, United Kingdom
| | - Joe Kai
- Primary Care Stratified Medicine, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Nadeem Qureshi
- Primary Care Stratified Medicine, Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Singhal AB, Silverman SB, Romero JM, Lang-Orsini M. Case 6-2023: A 68-Year-Old Man with Recurrent Strokes. N Engl J Med 2023; 388:747-757. [PMID: 36812438 DOI: 10.1056/nejmcpc2211368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Affiliation(s)
- Aneesh B Singhal
- From the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Harvard Medical School - both in Boston
| | - Scott B Silverman
- From the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Harvard Medical School - both in Boston
| | - Javier M Romero
- From the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Harvard Medical School - both in Boston
| | - Melanie Lang-Orsini
- From the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., S.B.S.), Radiology (J.M.R.), and Pathology (M.L.-O.), Harvard Medical School - both in Boston
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Stroke mortality in cancer survivors: A population-based study in Japan. Thromb Res 2023; 222:140-148. [PMID: 36682150 DOI: 10.1016/j.thromres.2023.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/22/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The association between cancer survivors and stroke deaths remains unclear. We aimed to evaluate the risk of fatal stroke in patients with cancer. MATERIALS AND METHODS This study was conducted using data from the Osaka Cancer Registry and vital statistics in Japan, collected from 1985 to 2013. We extracted patient data and investigated the causes of death. Standardized mortality ratios were calculated to compare the risk of stroke in patients with cancer to that in the general population. Poisson regression models were used to estimate the risk of stroke in patients with cancer and other cancer subgroups. Stroke types were used for risk stratification. RESULTS We identified 688,473 eligible patients with cancer. The cohort contributed 2,668,126 person-years at risk. During the study period, 337,117 patients died; stroke was the cause of death in 5496 patients. Stroke types included cerebral infarction (3259), intracerebral hemorrhage (1539), subarachnoid hemorrhage (364), and other cerebrovascular diseases (334). The crude mortality rate from fatal stroke was 205.99 per 100,000 person-years. The standardized mortality ratio (95 % confidence interval) for fatal stroke was 1.75 (1.71-1.80). When stratified by stroke types, the ratios for cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage were 1.83 (1.76-1.89), 2.38 (2.26-2.50), and 2.28 (2.03-2.56), respectively. The risk of fatal stroke increased with time after cancer diagnosis. The multivariate Poisson regression model indicated that men were more likely to die of stroke than women. CONCLUSIONS Cancer survivors have a higher risk of fatal stroke than the general population across all stroke types.
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Kitahama T, Otsuka S, Sugiura T, Ashida R, Ohgi K, Yamada M, Uesaka K. A case of pancreatic head cancer with Trousseau's syndrome treated with radical resection and anticoagulant therapy. Surg Case Rep 2023; 9:6. [PMID: 36633733 PMCID: PMC9837346 DOI: 10.1186/s40792-023-01585-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The primary disease of Trousseau's syndrome is often highly advanced cancer, and treatment of the primary disease after cerebral infarction is often difficult. We herein report a case of pancreatic head cancer with Trousseau's syndrome treated with radical resection and anticoagulant therapy. CASE PRESENTATION A 78-year-old man was admitted with dizziness and diagnosed with cerebral infarction. Abdominal contrast-enhanced computed tomography for a thorough checkup indicated borderline resectable pancreatic head cancer. Radical resection after neoadjuvant chemotherapy (NAC; gemcitabine plus nab-paclitaxel) was scheduled. During the second course of NAC, multiple cerebral infarctions recurred, and the patient was diagnosed with Trousseau's syndrome. Continuous intravenous infusion of heparin was started for cerebral infarction. Since it was impossible to continue NAC and there was no worsening of imaging findings, radical resection was planned. Thereafter, he underwent pancreatoduodenectomy with superior mesenteric vein resection. The patient progressed well and was discharged on the 19th day after surgery. He continued subcutaneous injection of heparin at home and is alive without recurrence of cancer or cerebral infarction at more than 21 months after surgery. CONCLUSION Surgical treatment may be an option for pancreatic cancer with Trousseau's syndrome under favorable conditions.
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Affiliation(s)
- Takumi Kitahama
- grid.415797.90000 0004 1774 9501Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimongakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Shimpei Otsuka
- grid.415797.90000 0004 1774 9501Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimongakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Teiichi Sugiura
- grid.415797.90000 0004 1774 9501Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimongakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Ryo Ashida
- grid.415797.90000 0004 1774 9501Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimongakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Katsuhisa Ohgi
- grid.415797.90000 0004 1774 9501Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimongakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Mihoko Yamada
- grid.415797.90000 0004 1774 9501Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimongakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
| | - Katsuhiko Uesaka
- grid.415797.90000 0004 1774 9501Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimongakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777 Japan
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Zhang X, Zhang C, Ma Z, Zhang Y. Soluble P-selectin level in patients with cancer-associated venous and artery thromboembolism: a systematic review and meta-analysis. Arch Med Sci 2023; 19:274-282. [PMID: 36817657 PMCID: PMC9897104 DOI: 10.5114/aoms/159039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/05/2013] [Indexed: 01/18/2023] Open
Affiliation(s)
- Xueli Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, China
- Department of Respiratory and Critical Care Medicine, Beijing Shunyi District Hospital, Beijing, China
| | - Chen Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, China
| | - Zhuo Ma
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yuhui Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, China
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