IMPORTANCE It is uncertain whether coronavirus disease 2019 (COVID-19) is associated with a higher risk of ischemic stroke than would be expected from a viral respiratory infection. OBJECTIVE To compare the rate of ischemic stroke between patients with COVID-19 and patients with influenza, a respiratory viral illness previously associated with stroke.

Background The risk of arterial thromboembolism in patients with cancer is incompletely understood. Objectives The authors aimed to better define this epidemiological relationship, including the effects of cancer stage. Methods Using the Surveillance Epidemiology and End Results-Medicare linked database, we identified patients with a new primary diagnosis of breast, lung, prostate, colorectal, bladder, pancreatic, or gastric cancer or non-Hodgkin lymphoma from 2002 through 2011. They were individually matched by demographics and comorbidities to a Medicare enrollee without cancer, and each pair was followed through 2012. Validated diagnosis codes were used to identify arterial thromboembolism, defined as myocardial infarction or ischemic stroke. Cumulative incidence rates were calculated using competing risk survival statistics. Cox hazards analysis was used to compare rates between groups at discrete time points. Results We identified 279,719 pairs of patients with cancer and matched controls. The 6-month cumulative incidence of arterial thromboembolism was 4.7% (95% confidence interval [CI]: 4.6% to 4.8%) in patients with cancer compared to 2.2% (95% CI: 2.1% to 2.2%) in controls (HR: 2.2; 95% CI: 2.1 to 2.3). The 6-month cumulative incidence of myocardial infarction was 2.0% (95% CI: 1.9% to 2.0%) in patients with cancer compared with 0.7% (95% CI: 0.6% to 0.7%) in controls (HR: 2.9; 95% CI: 2.8 to 3.1). The 6-month cumulative incidence of ischemic stroke was 3.0% (95% CI: 2.9% to 3.1%) in patients with cancer compared to 1.6% (95% CI: 1.6% to 1.7%) in controls (HR: 1.9; 95% CI: 1.8 to 2.0). Excess risk varied by cancer type (greatest for lung), correlated with cancer stage, and generally had resolved by 1 year. Conclusions Patients with incident cancer face a substantially increased short-term risk of arterial thromboembolism.

Background The postpartum state is associated with a substantially increased risk of thrombosis. It is uncertain to what extent this heightened risk persists beyond the conventionally defined 6-week postpartum period. Methods Using claims data on all discharges from nonfederal emergency departments and acute care hospitals in California, we identified women who were hospitalized for labor and delivery between January 1, 2005, and June 30, 2010. We used validated diagnosis codes to identify a composite primary outcome of ischemic stroke, acute myocardial infarction, or venous thromboembolism. We then used conditional logistic regression to assess each patient's likelihood of a first thrombotic event during sequential 6-week periods after delivery, as compared with the corresponding 6-week period 1 year later. Results Among the 1,687,930 women with a first recorded delivery, 1015 had a thrombotic event (248 cases of stroke, 47 cases of myocardial infarction, and 720 cases of venous thromboembolism) in the period of 1 year plus up to 24 weeks after delivery. The risk of primary thrombotic events was markedly higher within 6 weeks after delivery than in the same period 1 year later, with 411 events versus 38 events, for an absolute risk difference of 22.1 events (95% confidence interval [CI], 19.6 to 24.6) per 100,000 deliveries and an odds ratio of 10.8 (95% CI, 7.8 to 15.1). There was also a modest but significant increase in risk during the period of 7 to 12 weeks after delivery as compared with the same period 1 year later, with 95 versus 44 events, for an absolute risk difference of 3.0 events (95% CI, 1.6 to 4.5) per 100,000 deliveries and an odds ratio of 2.2 (95% CI, 1.5 to 3.1). Risks of thrombotic events were not significantly increased beyond the first 12 weeks after delivery. Conclusions Among patients in our study, an elevated risk of thrombosis persisted until at least 12 weeks after delivery. However, the absolute increase in risk beyond 6 weeks after delivery was low. (Funded by the National Institute of Neurological Disorders and Stroke.)

Objective To examine the association between incident cancer and the subsequent risk of stroke. Methods Using the Surveillance Epidemiology and End Results-Medicare linked database, we identified patients with a new primary diagnosis of breast, colorectal, lung, pancreatic, or prostate cancer from 2001 through 2007. These patients were individually matched by age, sex, race, registry, and medical comorbidities to a group of Medicare enrollees without cancer, and each pair was followed through 2009. Validated diagnosis codes were used to identify a primary outcome of stroke. Cumulative incidence rates were calculated using competing risk survival statistics. Results Among 327,389 pairs of cancer patients and matched controls, the 3-month cumulative incidence of stroke was generally higher in patients with cancer. Cumulative incidence rates were 5.1% (95% confidence interval [CI], 4.9–5.2%) in patients with lung cancer compared to 1.2% (95% CI, 1.2–1.3%) in controls (p<0.001), 3.4% (95% CI, 3.1–3.6%) in patients with pancreatic cancer compared to 1.3% (95% CI, 1.1–1.5%) in controls (p<0.001), 3.3% (95% CI, 3.2–3.4%) in patients with colorectal cancer compared to 1.3% (95% CI, 1.2–1.4%) in controls (p<0.001), 1.5% (95% CI, 1.4–1.6%) in patients with breast cancer compared to 1.1% (95% CI, 1.0–1.2%) in controls (p<0.001), and 1.2% (95% CI, 1.1–1.3%) in patients with prostate cancer compared to 1.1% (95% CI, 1.0–1.2%) in controls (p=0.085). Excess risks attenuated over time and were generally no longer present beyond 1 year. Interpretation Incident cancer is associated with an increased short-term risk of stroke. This risk appears highest with lung, pancreatic, and colorectal cancers.

Currently 1 in 10 patients with ischemic stroke have comorbid cancer, and this frequency is expected to increase with continued advances in cancer therapeutics prolonging median survival. Well known for its association with venous thrombosis, cancer has recently emerged as a significant risk factor for arterial thromboembolism, including stroke; however, the underlying mechanisms are uncertain. In addition, the optimal strategies to prevent and acutely treat stroke in cancer patients are yet to be established. This review summarizes the current evidence on ischemic stroke risk, biomarkers, pathophysiology, treatments, and prognosis in cancer patients, emphasizing knowledge gaps and the potential strategies to address them. Ann Neurol 2018;83:873-883.

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Patients with acute ischemic stroke in the setting of active cancer (especially adenocarcinoma) face a substantial short-term risk of recurrent ischemic stroke and other types of thromboembolism.

We found that hypertonic saline is more effective than mannitol for the treatment of elevated intracranial pressure. Our meta-analysis is limited by the small number and size of eligible trials, but our findings suggest that hypertonic saline may be superior to the current standard of care and argue for a large, multicenter, randomized trial to definitively establish the first-line medical therapy for intracranial hypertension.