Related Subjects:
|Neurological History taking
|Causes of Stroke
|Ischaemic Stroke
|Subarachnoid Haemorrhage
|Small Vessel Disease
|Vascular Dementia
|Dementias
|CADASIL
|CARASIL
|Cerebral Arterial Perfusion and Clinical Correlates
|Anterior circulation Brain
|Posterior circulation Brain
|Acute Stroke Assessment (ROSIER&NIHSS)
|Carotid Artery dissection
|Vertebral artery dissection
|Acute Stroke Assessment (ROSIER&NIHSS)
|Atrial Fibrillation
|Atrial Myxoma
|Causes of Stroke
|Ischaemic Stroke
|Cancer and Stroke
|Cerebral Venous thrombosis
|Cardioembolic stroke
|CT Basics for Stroke
|Endocarditis and Stroke
|Haemorrhagic Stroke
|Stroke Thrombolysis
|Hyperacute Stroke Care
|Anatomy and Physiology of the Brain
|Cryptogenic stroke
|Carotid Web
|Anterior / Medial Medullary Infarct (Dejerine Syndrome)
🧠 Introduction
- The relationship between stroke and cancer is complex and multifactorial.
- Stroke may even be the first presentation of occult cancer, especially in high-risk cancers (e.g. adenocarcinoma, metastatic disease).
- In the USA: Cancer = 2nd leading cause of death; Stroke = 4th.
- In cryptogenic stroke, particularly with embolic appearance, occult cancer should be considered.
🎯 Cancers Commonly Linked with Stroke
- 🫁 Lung cancer
- 🧬 Prostate cancer
- 🧠 Primary brain tumours
- 🩸 Haematological malignancies
- 🩺 Pancreatic cancer
- 👩⚕️ Gynaecological cancers
💥 Cancers Associated with Haemorrhagic Metastases
- 🖤 Melanoma
- 🩺 Renal cell carcinoma
- 🧵 Thyroid carcinoma
- 🧫 Germ cell tumours
⚙️ Aetiological Mechanisms
- Direct tumour vascular compression (arterial, venous, capillary).
- Procoagulant effects of malignancy or therapy.
- 🧪 Leukostasis in leukaemia.
- Cardioembolism from marantic (non-infective) endocarditis.
- 📡 Radiation vasculopathy (esp. head/neck cancers).
- Overlap with classic vascular risks: HTN, diabetes, AF, smoking.
🔬 Mechanisms and Associated Tumours
- Hypercoagulability: adenocarcinomas (breast, lung, prostate, pancreas) → embolic infarcts.
- Venous-to-arterial embolism: via PFO in hypercoagulable states.
- NBTE (marantic endocarditis): sterile vegetations (aortic/mitral), esp. adenocarcinoma → multiple widespread strokes.
- Direct tumour compression: glioblastoma/metastases → MCA territory large strokes.
- Tumour embolism: atrial myxoma, cardiac metastasis.
- Hyperviscosity: myeloma, Waldenström’s, PV → small vessel strokes.
- Angioinvasion: lymphoma → multi-territory infarcts.
- Post-radiation vasculopathy: carotid stenosis after radiotherapy.
- Chemotherapy: e.g. cisplatin, methotrexate → variable mechanisms.
🩺 Clinical Presentation
- Typical ischaemic syndromes or haemorrhagic strokes.
- Silent infarcts are common on MRI.
- DVT/PE alongside stroke strongly suggests cancer-related hypercoagulability.
❤️ Marantic Endocarditis (NBTE)
- Nonbacterial fibrin–platelet vegetations on valves (aortic > mitral).
- Occurs in advanced malignancy, esp. adenocarcinoma.
- No infection → negative blood cultures.
- Echo (esp. TOE) may show vegetations.
- Leads to recurrent embolic strokes.
🔍 Investigations
- 🧪 Bloods: FBC, ESR, CRP, U&E, TFTs.
- 🧠 Neuroimaging: CT/MRI ± contrast for infarct/haemorrhage/metastasis.
- 📈 ECG (AF, arrhythmias).
- 💓 Echocardiogram/TOE if NBTE suspected.
- 🎯 Cancer staging where relevant.
🔎 Differentials
- Other prothrombotic disorders (e.g. antiphospholipid).
- Primary CNS vasculitis.
💊 Management
- 🏥 Shared care: Stroke, oncology, haematology teams collaborate.
- ⚖️ Balance between stroke prevention and bleeding risk (esp. thrombocytopenia, metastases).
- 💉 Anticoagulation: LMWH preferred (especially if marantic endocarditis).
- 🛡️ VTE prophylaxis vital in immobile cancer patients.
- 🎯 Tailor to cancer prognosis, patient wishes, and bleeding risk.
📚 References
💡 Key Exam Pearl: Multiple embolic infarcts in different territories + raised D-dimer + weight loss → always think of occult cancer and consider NBTE.
