Should cerebral ischemic events in cancer patients be considered a manifestation of hypercoagulability?

Background and Purpose— Cancer is a risk factor for ischemic stroke. Little is known about cancer among young adults with ischemic stroke. We studied the frequency of cancer and its association with long-term risk of death among young patients with first-ever ischemic stroke. Methods— 1002 patients aged 15 to 49 years, registered in the Helsinki Young Stroke Registry, and with a median follow-up of 10.0 years (interquartile range 6.5–13.8) after stroke were included. Historical and follow-up data were derived from the Finnish Care Register and Statistics Finland. Survival between groups was compared with the Kaplan–Meier life-table method, and Cox proportional hazard models were used to identify factors associated with mortality. Results— One or more cancer diagnosis was made in 77 (7.7%) patients, of whom 39 (3.9%) had cancer diagnosed prestroke. During the poststroke follow-up, 41 (53.2%) of the cancer patients died. Median time from prestroke cancer to stroke was 4.9 (1.0–9.5) years and from stroke to poststroke cancer was 6.7 (2.7–10.9) years. Poststroke cancer was associated with age >40 years, heavy drinking, and cigarette smoking. The cumulative mortality was significantly higher among the cancer patients (68.6%, 95% confidence interval 52.0%–85.3%) compared with patients without cancer (19.7%, 95% confidence interval 16.3%–23.2%). Active cancer at index stroke, melanoma, and lung/respiratory tract cancer had the strongest independent association with death during the follow-up when adjusted for known poststroke mortality prognosticators. Conclusions— Cancer, and especially active cancer and no other apparent cause for stroke, is associated with unfavorable survival among young stroke patients.

Section: Discussionmentioning

confidence: 80%

mentioning

confidence: 99%

Cancer in Young Adults With Ischemic Stroke

Aarnio

Joensuu

Haapaniemi

et al. 2015

“…Previous studies reported that the stroke patterns and vascular risk factors in cancer patients were not significantly different compared with the general population. [5][6][7] Autopsy studies demonstrated that the most common cause of ischemic stroke (78% asymptomatic) in patients with cancer was atherosclerosis. 1 On the contrary, others reported that embolisms, not including those of cardiac origin, were the most common cause of ischemic stroke in cancer patients.…”

mentioning

confidence: 99%

Ischemic Stroke in Cancer Patients With and Without Conventional Mechanisms

Kim

Hong

Kim

et al. 2010

207

234

Background and Methods-To assess the precise mechanisms of stroke in cancer patients, we analyzed the data for cancer patients with acute ischemic stroke registered from 6 centers in South Korea. Clinical features, risk factors, diffusion-weighted imaging lesion patterns, and laboratory findings including D-dimer levels were compared between patients with conventional stroke mechanisms (CSMs) and cryptogenic group. Results-A total of 161 patients were included in this study: 97 (60.2%) patients in the CSM group and 64 (39.8%) in the cryptogenic group. Patients in the CSM group were older and vascular risk factors were more prevalent than in the cryptogenic group. Diffusion-weighted imaging patterns of multiple lesions involving multiple arterial territories were observed more frequently in the cryptogenic group than in the CSM group. In addition, levels of the D-dimer were higher in the cryptogenic group than in the CSM group (11.5Ϯ14.6 versus 3.6Ϯ10.3 g/dL). In multivariate analysis, the diffusion-weighted imaging lesion pattern of multiple vascular territories (odds ratio, 11.2; 95% CI, 3.74 to 33.3), and D-dimer levels of Ͼ1.11 g/dL (odds ratio, 10.6; 95% CI, 3.29 to 33.8) were associated independently with the cryptogenic group. Conclusions-Stroke outside of CSM occurred in a large number in cancer patients. In stroke patients with cancer, D-dimer levels and diffusion-weighted imaging lesion patterns may be helpful in early identification of non-CSMs (especially coagulopathy associated with cancer) and possibly in guiding preventive strategies for stroke. (Stroke. 2010;41:798-801.)

“…4,5 A small number of earlier studies on this topic generated conflicting results. [6][7][8][9][10][11][12] The largest study including 161 patients by Kim et al in 2010 differentiated between patients with cancer+stroke with and without conventional stroke etiologies and renewed the idea of cancer-associated hypercoagulation as an important stroke etiology. 13 Significantly higher d-dimer levels as well as a significantly higher rate of multiply affected vascular territories in the group of patients without conventional stroke etiology supported the idea of cancer-associated hypercoagulation with resulting cerebral embolism.…”

mentioning

confidence: 99%

Stroke and Cancer

Schwarzbach

Schaefer

Ebert

et al. 2012

223

117

Background and Purpose-The importance of cancer-associated hypercoagulability as a possible stroke etiology in patients with cancer has received relatively little attention to date. A recent study has suggested that cancer-associated hypercoagulation may be of special importance in the absence of conventional stroke mechanisms. Methods-We identified patients with ischemic stroke sequentially admitted to our stroke center with the additional diagnosis of active and malignant cancer from 2002 to 2011. By using our prospectively collected stroke, MRI, and laboratory data banks, the etiology and risk factors of stroke, types of cancer, deep vein thrombosis/pulmonary embolism, d-dimer levels, and diffusion-weighted imaging lesion patterns were compared to an age-and sex-matched control group. Patients with cancer with a conventional stroke etiology and patients with an unidentified and/or cancer-associated stroke etiology were analyzed separately. Results-One hundred forty patients with cancer and 140 control subjects were included. Unidentified stroke (P<0.001) and infarction in multiple vascular territories (P<0.001) were significantly more frequent and d-dimer levels significantly higher (P<0.05) in patients with cancer. Vice versa, risk factors such as hypertension (P<0.05) and hyperlipidemia (P<0.01) were more prevalent in control subjects. Deep vein thrombosis and pulmonary embolism were more frequent (P<0.01) and d-dimer levels higher (P<0.01) in the patients with unidentified and/or cancerassociated stroke etiology compared to the patients with cancer with a conventional stroke etiology. Lung and pancreatic cancer were significantly overrepresented and d-dimer levels higher in these patients compared with other patients with cancer (P<0.01). Conclusions-Our data confirm the concept of cancer-associated hypercoagulation as a widely underestimated important stroke risk factor in patients with cancer, especially in those with severely elevated