Multiple recurrent ischaemic strokes in a patient with cancer: is there a role for the initiation of anticoagulation therapy for secondary stroke prevention?

Suero-Abreu, Giselle Alexandra; Cheng, Jing; Then, Ryna

doi:10.1136/bcr-2016-218105

Cited by 4 publications

(4 citation statements)

References 41 publications

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“…cisplatin, methotrexate, L-asparaginase) 255,256 and antiangiogenic agents (viz. paclitaxel, angiostatin) [257][258][259] have also been associated with cerebral stroke. For example, the treatment of GBM with Bevacizumab shows a stroke rate of 1.9%.…”

Section: Glioma Leads To Ischemic Stroke and Brain Injuriesmentioning

confidence: 99%

The interrelationship between cerebral ischemic stroke and glioma: a comprehensive study of recent reports

Ghosh

Chakraborty

Sarkar

et al. 2019

Sig Transduct Target Ther

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Glioma and cerebral ischemic stroke are two major events that lead to patient death worldwide. Although these conditions have different physiological incidences,~10% of ischemic stroke patients develop cerebral cancer, especially glioma, in the postischemic stages. Additionally, the high proliferation, venous thrombosis and hypercoagulability of the glioma mass increase the significant risk of thromboembolism, including ischemic stroke. Surprisingly, these events share several common pathways, viz. hypoxia, cerebral inflammation, angiogenesis, etc., but the proper mechanism behind this co-occurrence has yet to be discovered. The hypercoagulability and presence of the D-dimer level in stroke are different in cancer patients than in the noncancerous population. Other factors such as atherosclerosis and coagulopathy involved in the pathogenesis of stroke are partially responsible for cancer, and the reverse is also partially true. Based on clinical and neurosurgical experience, the neuronal structures and functions in the brain and spine are observed to change after a progressive attack of ischemia that leads to hypoxia and atrophy. The major population of cancer cells cannot survive in an adverse ischemic environment that excludes cancer stem cells (CSCs). Cancer cells in stroke patients have already metastasized, but early-stage cancer patients also suffer stroke for multiple reasons. Therefore, stroke is an early manifestation of cancer. Stroke and cancer share many factors that result in an increased risk of stroke in cancer patients, and vice-versa. The intricate mechanisms for stroke with and without cancer are different. This review summarizes the current clinical reports, pathophysiology, probable causes of co-occurrence, prognoses, and treatment possibilities.

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Section: Glioma Leads To Ischemic Stroke and Brain Injuriesmentioning

confidence: 99%

The interrelationship between cerebral ischemic stroke and glioma: a comprehensive study of recent reports

Ghosh

Chakraborty

Sarkar

et al. 2019

Sig Transduct Target Ther

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“…Approximately 20% of patients with strokes of undetermined cause have an occult malignancy at the time of presentation [ 5 ]. Studies show that a stroke can be the initial sign of cancer, with 84% of these patients experiencing a second stroke within four months [ 6 ].…”

Section: Discussionmentioning

confidence: 99%

“…Common cancer types associated with recurrent stroke include breast, gynecological, cholangiocarcinoma, lung, pancreatic, gastric, and metastatic cancer [ 6 ]. This is a rare case report demonstrating squamous cell carcinoma of the head/neck as a cause of multifocal embolic stroke.…”

Section: Discussionmentioning

confidence: 99%

“…A cutoff of ≥5.5 mg/l provided high specificity (99.6%) irrespective of multiple territory infarctions, suggesting its potential for malignancy detection in stroke patients. However, the predictive utility of D-dimer levels can be influenced by various factors such as tumor burden, age, and diabetes, complicating its interpretation [ 6 ].…”

Section: Discussionmentioning

confidence: 99%

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Recurrent Multifocal Embolic Strokes in a 50-Year-Old Male: Unmasking Occult Squamous Cell Carcinoma

Prabakar,

Sabesan,

Emenogu

et al. 2023

Cureus

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Recurrent cryptogenic embolic strokes pose a diagnostic challenge, often necessitating an extensive evaluation to determine the underlying cause. Cancer-related stroke is a frequently overlooked etiology, accounting for a substantial proportion of cryptogenic strokes. This case study underscores the importance of considering occult malignancies in patients with recurrent strokes of unknown origin and emphasizes the need for a comprehensive diagnostic workup to detect hidden malignancies.A 50-year-old male with a complex medical history presented with expressive aphasia and blurred vision resembling previous stroke episodes. Neurological examinations revealed right hemianopsia, paraphasia, and abnormal coordination. Neuroimaging studies showed multiple chronic infarctions, a large hemorrhagic infarction in the left posterior cerebral artery territory, and a small acute-to-subacute left parietal infarction. Due to the time of presentation and the presence of hemorrhagic transformation, the patient did not meet the criteria for intravenous tissue plasminogen activator administration. Given the recurrent nature of the strokes, an extensive evaluation was initiated to determine the underlying cause. Vascular imaging, including magnetic resonance angiography (MRA) of the head and neck and a CT angiogram, showed no significant stenosis. Vasculitis workup and cardiac evaluation yielded negative results. The blood workup was notable for elevated D-dimer levels. The involvement of multiple vascular territories and recurrent stroke despite adequate treatment and the absence of traditional risk factors for stroke raised a high clinical suspicion of occult malignancy. Further investigations led to the diagnosis of locally advanced squamous cell carcinoma (P16+), metastatic to the right neck lymph nodes (cTxN3M0). Although the primary source of cancer could not be identified, the P16+ status suggests the right tonsil or base of the tongue as the probable origin. Anticoagulation therapy was initiated, and the patient was scheduled for chemoradiation therapy.Although routine cancer investigation is not justified in ischemic strokes, the possibility of an occult malignancy should be considered in the presence of multifocal infarctions across different vascular territories with elevated D-dimer levels, particularly when traditional risk factors have been ruled out. A detailed physical exam can help localize the malignancy and early identification of occult malignancies can guide appropriate management strategies and help prevent future strokes. Further clinical trials are needed to establish optimal therapeutic approaches for preventing stroke recurrence in cancer-related strokes.

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Cisplatin/gemcitabine

2017

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Multiple recurrent ischaemic strokes in a patient with cancer: is there a role for the initiation of anticoagulation therapy for secondary stroke prevention?

Cited by 4 publications

References 41 publications

The interrelationship between cerebral ischemic stroke and glioma: a comprehensive study of recent reports

The interrelationship between cerebral ischemic stroke and glioma: a comprehensive study of recent reports

Recurrent Multifocal Embolic Strokes in a 50-Year-Old Male: Unmasking Occult Squamous Cell Carcinoma

Cisplatin/gemcitabine

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