Advertisement

Clinical features and prognostic factors in patients with cancer-associated multiple ischemic stroke: A retrospective observational study

      Highlights

      • Cancer-mediated hypercoagulability sometimes develops multiple ischemic strokes that involve various cerebrovascular territories (multiple CAIS).
      • In our study, multiple CAIS occurred in elderly patients with advanced cancer, mostly independent in daily living with relatively high KPS scores, but their survival was ∼1–2 months.
      • Hypoalbuminemia at the onset of multiple CAIS was significantly associated with short survival.

      Abstract

      Objectives

      To investigate the patient demographics, survival after diagnosis, and prognostic factors among patients with multiple-territory cerebral infarctions due to cancer-associated ischemic stroke (multiple CAIS).

      Materials and methods

      We performed a retrospective review of the medical records from a 10-year period of consecutive patients with multiple CAIS, defined as (1) newly developed multiple cerebral infarctions involving two or more cerebrovascular territories, (2) association with active cancer diagnosed or treated <6 months before or after stroke, and (3) exclusion of obvious etiologies other than cancer-associated coagulopathy in routine screening. We extracted demographic features, stroke severity and characteristics, cancer characteristics, comorbidities, and laboratory data. Univariable Cox proportional hazards regression was used to idenify the prognostic factors.

      Results

      The median age was 74 years (interquartile range, 68.3–80.5), and the median survival after diagnosis was 44.5 (27.3–76.8) days in 26 patients with complete follow-up. The median National Institutes of Health Stroke Scale was 5.5 (2.0–9.0). Twenty (76.9%) patients had received a cancer diagnosis prior to the diagnosis of multiple CAIS, and most patients (25 patients, 96.2%) had stage IV cancer. Univariate analysis showed that high serum albumin (hazard ratio, 0.31; 95% confidence interval, 0.11–0.88) was significantly associated with prolonged survival, whereas stroke severity and comorbidities were not associated with survival.

      Conclusion

      Multiple CAIS predominantly occurred in elderly patients with advanced cancer, and their survival was short. Serum albumin levels were significantly associated with prognosis, indicating the poor general condition associated with cancers may affect prognosis.

      Keywords

      Abbreviations:

      CAIS (Cancer-associated ischemic stroke), DVT (Deep vein thrombosis), ESUS (Embolic stroke of undetermined source), KPS (Karnofsy Performance Scale), mRS (modified Rankin Scale), NIHSS (National Institutes of Health Stroke Scale)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Varki A.
        Trousseau's syndrome: multiple definitions and multiple mechanisms.
        Blood. 2007; 110: 1723-1729
        • Navi B.B.
        • Reiner A.S.
        • Kamel H.
        • et al.
        Risk of arterial thromboembolism in patients with cancer.
        J Am Coll Cardiol. 2017; 70: 926-938
        • Navi B.B.
        • Kasner S.E.
        • Elkind M.S.V.
        • et al.
        Cancer and embolic stroke of undetermined source.
        Stroke. 2021; 52: 1121-1130
        • Singhal A.B.
        • Topcuoglu M.A.
        • Buonanno F.S.
        Acute ischemic stroke patterns in infective and nonbacterial thrombotic endocarditis: a diffusion-weighted magnetic resonance imaging study.
        Stroke. 2002; 33: 1267-1273
        • Kim S.G.
        • Hong J.M.
        • Kim H.Y.
        • et al.
        Ischemic stroke in cancer patients with and without conventional mechanisms: a multicenter study in Korea.
        Stroke. 2010; 41: 798-801
        • Nouh A.M.
        • Staff I.
        • Finelli P.F.
        Three territory sign: An MRI marker of malignancy-related ischemic stroke (trousseau syndrome).
        Neurol Clin Pract. 2019; 9: 124-128
        • Cestari D.M.
        • Weine D.M.
        • Panageas K.S.
        • et al.
        Stroke in patients with cancer: incidence and etiology.
        Neurology. 2004; 62: 2025-2030
        • Akatsuka K.
        • Hattori N.
        • Ito M.
        • et al.
        The clinical features of 40 patients with trousseau syndrome at Toyota Kosei hospital.
        Nosotchu (Jpn J Stroke). 2018; 40 (in Japanese): 421-426
        • Suero-Abreu G.A.
        • Cheng J.Z.
        • Then R.K.
        Multiple recurrent ischaemic strokes in a patient with cancer: is there a role for the initiation of anticoagulation therapy for secondary stroke prevention?.
        BMJ Case Rep. 2017; 3 (bcr2017:2016218105)
        • Navi B.B.
        • Singer S.
        • Merkler A.E.
        • et al.
        Cryptogenic subtype predicts reduced survival among cancer patients with ischemic stroke.
        Stroke. 2014; 45: 2292-2297
        • Chaturvedi S.
        • Ansell J.
        • Recht L.
        Should cerebral ischemic events in cancer patients be considered a manifestation of hypercoagulability?.
        Stroke. 1994; 25: 1215-1218
        • Amico L.
        • Caplan L.R.
        • Thomas C.
        Cerebrovascular complications of mucinous cancers.
        Neurology. 1989; 39: 522-526
        • Dearborn J.L.
        • Urrutia V.C.
        • Zeiler S.R.
        Stroke and cancer–a complicated relationship.
        J Neurol Transl Neurosci. 2014; 2: 1039
        • Bick R.L.
        Cancer-associated thrombosis.
        N Engl J Med. 2003; 349: 109-111
        • Gon Y.
        • Okazaki S.
        • Terasaki Y.
        • et al.
        Characteristics of cryptogenic stroke in cancer patients.
        Ann Clin Transl Neurol. 2016; 3: 280-287
        • Kim S.J.
        • Park J.H.
        • Lee M.-.J.
        • et al.
        Clues to occult cancer in patients with ischemic stroke.
        PLoS ONE. 2012; 7: e44959
        • Lee E.J.
        • Nah H.W.
        • Kwon J.Y.
        • et al.
        Ischemic stroke in patients with cancer: is it different from usual strokes?.
        Int J Stroke. 2014; 9: 406-412
        • Rogers L.R.
        Cerebrovascular complications in patients with cancer.
        Semin Neurol. 2010; 30: 311-319
        • Nazha B.
        • Moussaly E.
        • Zaarour M.
        • et al.
        Hypoalbuminemia in colorectal cancer prognosis: nutritional marker or inflammatory surrogate?.
        World J Gastrointest Surg. 2015; 27: 370-377
        • McMillan D.C.
        • Watson W.S.
        • O'Gorman P.
        • et al.
        Albumin concentrations are primarily determined by the body cell mass and the systemic inflammatory response in cancer patients with weight loss.
        Nutr Cancer. 2001; 39: 210-213
        • McMillan D.C.
        Systemic inflammation, nutritional status and survival in patients with cancer.
        Curr Opin Clin Nutr Metab Care. 2009; 12: 223-226
        • Crumley A.B.
        • Stuart R.C.
        • McKernan M.
        • et al.
        Is hypoalbuminemia an independent prognostic factor in patients with gastric cancer?.
        World J Surg. 2010; 34: 2393-2398
        • Carter A.M.
        • Catto A.J.
        • Mansfield M.W.
        • et al.
        Predictive variables for mortality after acute ischemic stroke.
        Stroke. 2007; 38: 1873-1880
        • Fan H.
        • Shao Z.Y.
        • Xiao Y.Y.
        • et al.
        Comparison of the glasgow prognostic score (GPS) and the modified glasgow prognostic score (mGPS) in evaluating the prognosis of patients with operable and inoperable non-small cell lung cancer.
        J Cancer Res Clin Oncol. 2016; 142: 1285-1297
        • Okadome K.
        • Baba Y.
        • Yagi T.
        • et al.
        Prognostic nutritional index, tumor-infiltrating lymphocytes, and prognosis in patients with esophageal cancer.
        Ann Surg. 2020; 271: 693-700
        • Li W.
        • Li M.
        • Wang T.
        • et al.
        Controlling nutritional status (CONUT) score is a prognostic factor in patients with resected breast cancer.
        Sci Rep. 2020; 20: 6633
        • Jiang Y.
        • Xu D.
        • Song H.
        • et al.
        Inflammation and nutrition-based biomarkers in the prognosis of oesophageal cancer: a systematic review and meta-analysis.
        BMJ Open. 2021; 11e048324
        • Adams H.P.
        • Davis P.H.
        • Leira E.C.
        • et al.
        Baseline NIH stroke scale score strongly predicts outcome after stroke: a report of the trial of Org 10172 in acute stroke treatment (TOAST).
        Neurology. 1999; 53: 126-131
        • Wang Y.
        • Lim L.L.
        • Heller R.F.
        • et al.
        A prediction model of 1-year mortality for acute ischemic stroke patients.
        Arch Phys Med Rehabil. 2003; 84: 1006-1011
        • Kortazar-Zubizarreta I.
        • Pinedo-Brochado A.
        • Azkune-Calle I.
        • et al.
        Predictors of in-hospital mortality after ischemic stroke: a prospective, single-center study.
        Health Sci Rep. 2019; 2: e110
        • Nezu T.
        • Kitano T.
        • Kubo S.
        • et al.
        Impact of D-dimer levels for short-term or long-term outcomes in cryptogenic stroke patients.
        J Neurol. 2018; 265: 628-636
        • Ohara T.
        • Farhoudi M.
        • Bang O.Y.
        • et al.
        The emerging value of serum D-dimer measurement in the work-up and management of ischemic stroke.
        Int J Stroke. 2020; 15: 122-131
        • Bao L.
        • Zhang S.
        • Gong X.
        • et al.
        Trousseau syndrome related cerebral infarction: clinical manifestations, laboratory findings and radiological features.
        J Stroke Cerebrovasc Dis. 2020; 29104891
        • Wen H.M.
        • Lam W.W.
        • Rainer T.
        • et al.
        Multiple acute cerebral infarcts on diffusion-weighted imaging and risk of recurrent stroke.
        Neurology. 2004; 63: 1317-1319