Stroke is a disabling disease and can add to the burden of patients already suffering from cancer. Several major mechanisms of stroke exist in cancer patients, which can be directly tumour related, because of coagulation disorders, infections, and therapy related. Stroke can also occur as the first sign of cancer, or lead to its detection. The classical literature suggests that stroke occurs more frequently in cancer patients than in the average population. More recent studies report a very similar incidence between cancer and non-cancer patients. However, there are several cancer-specific types and causes of stroke in cancer patients, which need to be considered in each patient. This review classifies stroke into ischaemic, haemorrhagic, cerebral venous thrombosis and other rarer types of cerebrovascular disease. Its aim is to identify the types of stroke most frequently associated with cancer, and give a practical view on the most common and most specific types of stroke. The diagnosis of the cause of stroke in cancer patients is crucial for treatment and prevention. Management of different stroke types will be briefly discussed.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1600-0404.2008.01059.x

Stroke and cancer: a review

Numerous types of cancer have been shown to be associated with either ischemic or hemorrhagic stroke. In this review, the epidemiology and pathophysiology of stroke in cancer patients is discussed, while providing vital information on the diagnosis and management of patients with cancer and stroke. Cancer may mediate stroke pathophysiology either directly or via coagulation disorders that establish a state of hypercoagulation, as well as via infections. Cancer treatment options, such as chemotherapy, radiotherapy and surgery have all been shown to aggravate the risk of stroke as well. The clinical manifestation varies greatly depending upon the underlying cause; however, in general, cancer-associated strokes tend to appear as multifocal in neuroimaging. Furthermore, several serum markers have been identified, such as high D-Dimer levels and fibrin degradation products. Managing cancer patients with stroke is a delicate matter. The cancer should not be considered a contraindication in applying thrombolysis and recombinant tissue plasminogen activator (rTPA) administration, since the risk of hemorrhage in cancer patients has not been reported to be higher than that in the general population. Anticoagulation, on the contrary, should be carefully examined. Clinicians should weigh the benefits and risks of anticoagulation treatment for each patient individually; the new oral anticoagulants appear promising; however, low-molecular-weight heparin remains the first choice. On the whole, stroke is a serious and not a rare complication of malignancy. Clinicians should be adequately trained to handle these patients efficiently.

/pdf/cancer-associated-stroke-pathophysiology-detection-and-4lkd2fimml.pdf

Cancer-associated stroke: Pathophysiology, detection and management (Review)

Background and Purpose In patients already suffering from cancer, the additional occurrence of stroke can aggravate the burden of the disease. The purpose of this study was to compare risk factors for haemorrhagic and ischemic strokes in cancer and non-cancer patients. Methods A retrospective analysis, including 1,274 stroke patients admitted to a stroke unit, was conducted from 2004 to 2007. Classical risk factors for stroke and clinical outcome measures were compared between cancer and non-cancer patients. Results Twelve percent of stroke patients had an additional diagnosis of cancer. In the non-cancer population, 84% had ischemic and 16% had haemorrhagic strokes. In cancer patients, 86% had ischemic and 14% had haemorrhagic strokes. Vascular risk factors in cancer patients, including hypertension, atrial fibrillation, coronary vessel disease, smoking, hypercholesterolemia and diabetes mellitus, showed no difference compared to the non-cancer population. Only thrombotic events occurred more often in the cancer cohort. The most frequent cancer types were urogenital, breast and gastrointestinal. Regarding clinical outcome, cancer patients had an inferior neurological condition at discharge and a trend towards a longer stay in the stroke unit. Conclusions The frequency of ischemic and haemorrhagic stroke in tumour patients is similar to that in the non-cancer population. Cerebrovascular risk factors do not significantly vary between cancer and non-cancer patients. The higher frequency of thrombotic events in cancer patients may reflect a coagulation disorder, commonly found in patients with malignancy. Clinical outcome in cancer patients may be worsened by the pre-existent co-morbidity.

/pdf/stroke-in-cancer-patients-a-risk-factor-analysis-pqrtpwysok.pdf

Stroke in cancer patients: a risk factor analysis

Nonbacterial thrombotic endocarditis (NBTE), formerly known as marantic endocarditis, is a potentially overlooked condition that involves the formation of sterile, fibrin vegetations on heart valve leaflets. Often confused with classic infective endocarditis during its early stages, NBTE can lead to valvular dysfunction, heart failure, and systemic embolization when unchecked. The pathogenesis is not entirely clear but involves a preexisting hypercoagulable state. Diagnosis requires ruling out infection and establishing the presence of valvular vegetations using echocardiography. Therapy for NBTE includes treating the underlying disease, systemic anticoagulation and surgical intervention.

Nonbacterial Thrombotic Endocarditis: Pathogenesis, Diagnosis, and Management.

https://www.annalsthoracicsurgery.org/article/S0003-4975(12)02377-6/pdf

Current issues in the diagnosis and management of blood culture-negative infective and non-infective endocarditis

A descriptive term nonbacterial thrombotic endocarditis (NBTE) is used currently instead of the former name marantic endocarditis. The study describes 171 cases of NBTE encountered in autopsies over a period of 22 years (an incidence of 0.93% in adults). Malignancy was present in 59% of cases. Tumors relatively most frequently associated with NBTE were carcinomas of the ovaries, biliary system, pancreas, lung, and stomach. The vegetations were located mostly on the left-sided valves (mitral 64%, aortic 24%, both 9%). The involved valves were otherwise normal in 82%, and they were previously damaged in 18%. Systemic emboli from valvular vegetations occurred in 41% of patients, with splenic, cerebral, and renal circulations being most frequently affected. Pulmonary embolism was noted in 43%. The state of nutrition at autopsy was within normal limits in 35%; there was undernourishment or cachexia in 40%, and overweight or obesity in 22% of patients. The main pathogenetic factor in NBTE seems to be a state of hypercoagulation.

Steiner I

Papers

[Nonbacterial thrombotic endocarditis--a study of 171 case reports].