Evaluation and Treatment of a Patient With Recurrent Stroke in the Setting of Active Malignancy

Neilson, Lee E.; Rogers, Lisa; Sundararajan, Sophia

doi:10.1161/strokeaha.118.022088

“…Furthermore, studies have shown that patients with adenocarcinoma were prone to developing cancer-mediated hypercoagulability and microemboli [18,37]. Several studies have suggested that some epithelium-derived tumors, such as those originating from the lung, stomach, and bile ducts, are frequently adenocarcinomas and could systematically secrete mucins that bind to P-and L-selectins, inducing the formation of platelet-rich microthrombi [38,39]. Moreover, these cancers usually remain undiagnosed until they reach an advanced or metastatic stage.…”

Section: Discussionmentioning

confidence: 99%

Score for Predicting Active Cancer in Patients with Ischemic Stroke: A Retrospective Study

Jiang

¹

,

Shang

²

,

Zhao

³

et al. 2021

BioMed Research International

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Background. We aimed to examine the differences of clinical characteristics between patients with ischemic stroke with active cancer and those without cancer to develop a clinical score for predicting the presence of occult cancer in patients with ischemic stroke. Methods. This retrospective study enrolled consecutive adult patients with acute ischemic stroke who were admitted to our department between December 2017 and January 2019. The demographic, clinical, laboratory, and neuroimaging characteristics were compared between patients with ischemic stroke with active cancer and those without cancer. Multivariate analysis was performed to identify independent factors associated with active cancer. Subsequently, a predictive score was developed using the areas under the receiver operating characteristic curves based on these independent factors. Finally, Bayesian decision theory was applied to calculate the posterior probability of active cancer for finding the best scoring system. Results. Fifty-three (6.63%) of 799 patients with ischemic stroke had active cancer. The absence of a history of hyperlipidemia (odds ratio OR = 0.17 , 95% confidence interval (CI): 0.06–0.48, P < 0.01 ), elevated serum fibrinogen ( OR = 1.72 , 95% CI: 1.33–2.22, P < 0.01 ) and D-dimer levels ( OR = 1.43 , 95% CI: 1.24–1.64, P <0.01), and stroke of undetermined etiology ( OR = 22.87 , 95% CI: 9.91–52.78, P < 0.01 ) were independently associated with active cancer. A clinical score based on the absence of hyperlipidemia, serum fibrinogen level of ≥4.00 g/L, and D-dimer level of ≥2.00 μg/mL predicted active cancer with an area under the curve of 0.83 (95% CI: 0.77–0.89, P < 0.01 ). The probability of active cancer was 59% at a supposed prevalence of 6.63%, if all three independent factors were present in a patient with ischemic stroke. Conclusions. We devised a clinical score to predict active cancer in patients with ischemic stroke based on the absence of a history of hyperlipidemia and elevated serum D-dimer and fibrinogen levels. The use of this score may allow for early intervention. Further research is needed to confirm the implementation of this score in clinical settings.

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“…Guidelines on the utilization of antithrombotic therapy in the setting of acute ischemic stroke intervention in patients with underlying or suspected malignancy have not been established. Regarding secondary prevention in this patient population, common practice is to initiate low molecular weight heparin [ 11 , 12 , 13 , 14 ]. This common practice is based on studies designed for the management of recurrent deep venous thromboembolism as opposed to acute ischemic stroke.…”

Section: Discussionmentioning

confidence: 99%

“…This common practice is based on studies designed for the management of recurrent deep venous thromboembolism as opposed to acute ischemic stroke. Recently, evidence from the Hokusai VTE Cancer trial and Select-D Pilot trial showed noninferiority of oral factor Xa inhibitors when compared to LMWHs with respect to the outcome of recurrent venous thromboembolism or major bleeding [ 11 , 15 , 16 ]. In addition, efforts including multiple meta-analyses have been performed to establish guidelines for the role of anti-platelet therapy in primary, secondary, and tertiary prevention of stroke [ 5 ].…”

Section: Discussionmentioning

confidence: 99%

Multiple Thrombectomies in the Same Patient within One Month: Case Report of a Patient with Trousseau Syndrome and Acute Ischemic Stroke

Cicilioni

¹

,

Cristiano

²

,

Jacobson

³

et al. 2020

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Background and Importance: Since Trousseau’s initial publication, the development of thromboembolic events related to malignancy has been well established. The pathophysiology of this is understood to be through activation of the coagulation cascade through neoplastic cells themselves or the therapy initiated (chemotherapy or surgery). To date, there have been a variety of studies, such as the OASIS-CANCER trial, which highlight the relationship of hypercoagulability to ischemic stroke. Despite these efforts, clear evidence is lacking for the utilization of antiplatelet or anticoagulation therapy in the secondary prevention of stroke following mechanical thrombectomy in patients with suspected or confirmed malignancy. Clinical Presentation: A 71-year-old female with a history of immune thrombocytopenia, diabetes mellitus, and hypertension who was undergoing an evaluation for a lung nodule, later determined to be adenocarcinoma of the lung, underwent three successful mechanical thrombectomies for acute ischemic stroke with large vessel occlusion over a one month period. This patient had improved National Institutes of Health Stroke Scale (NIHSS) scores following each of her thrombectomies. However, her history of immune thrombocytopenia and underlying malignancy complicated her discharge medication regimen following each of her thrombectomies and may have contributed to her repeat strokes. Conclusion: Clear guidance is lacking regarding the utilization of antiplatelet and anticoagulation therapy in patients with suspected or confirmed malignancy following mechanical thrombectomy. Review of the literature suggests that controlling a patient’s hypercoagulability may lead to improved clinical outcomes, but further clinical trials are warranted.

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“…In spite of this, the use of thrombolysis in patients with cancer and stroke has increased significantly in recent times, although rates of use are one-third less than in patients with non-cancer-related ischemic strokes [3]. The 2018 American Stroke Association guidelines do not list active cancer as an absolute contraindication for thrombolysis, despite its efficacy and safety not being well established [20]. Although there are no trial data on the utility of ECR in patients with cancer, some studies have found similar rates of intracerebral hemorrhage after mechanical thrombectomy in patients with and without cancer [3].…”

Section: Discussionmentioning

confidence: 99%

“…This study was limited by low participant numbers, and requires larger trials to verify their results. As identified by the American Stroke Association and the European Stroke Organisation, the optimal antithrombotic regimen in cancer-associated strokes requires further high-powered, randomized studies [20, 25].…”

Section: Discussionmentioning

confidence: 99%

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

Siriratnam

¹

,

Kræmer

²

,

Sahathevan

³

2019

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Background Although there is an established association between cancer and stroke, the role of malignancy as a causative agent or comorbidity is not always clear. Moreover, there are no established guidelines on the acute treatment of cancer-associated stroke or optimal anticoagulation. This case report illustrates the significance of these practice gaps. Case presentation A 62-year-old Caucasian woman presented to our institute with acute neurological deficits and was found to have an occluded left middle cerebral artery on a computed tomographic angiogram. She was administered intravenous alteplase and underwent unsuccessful endovascular clot retrieval. Besides smoking and her age, she had no cerebrovascular risk factors, and the results of baseline investigations for the cause of stroke were negative. Subsequent computed tomography of the chest, abdomen, and pelvis showed metastatic malignancy, and in the context of a significantly elevated serum cancer antigen 19-9, we suspected a pancreatic primary cancer. A transthoracic echocardiogram demonstrated mitral regurgitation but no visible vegetation. The patient died of her illness. We made a diagnosis of cancer-associated stroke, specifically a likely case of nonbacterial thrombotic endocarditis. Conclusions This case highlights the importance of having a high threshold of suspicion for malignancy as a cause of stroke.

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Evaluation and Treatment of a Patient With Recurrent Stroke in the Setting of Active Malignancy

Cited by 9 publications

References 10 publications

Score for Predicting Active Cancer in Patients with Ischemic Stroke: A Retrospective Study

Score for Predicting Active Cancer in Patients with Ischemic Stroke: A Retrospective Study

Multiple Thrombectomies in the Same Patient within One Month: Case Report of a Patient with Trousseau Syndrome and Acute Ischemic Stroke

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

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