Related Subjects:
|Neurological History taking
|Causes of Stroke
|Acute Stroke Assessment (ROSIER&NIHSS)
|Atrial Fibrillation
|Atrial Myxoma
|Causes of Stroke
|Ischaemic Stroke
|Cancer and Stroke
|Cerebral Arterial Perfusion and Clinical Correlates
|Anterior circulation Brain
|Posterior circulation Brain
|Acute Stroke Assessment (ROSIER&NIHSS)
π§ 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.
π― Cancers Commonly Linked with Stroke
- π« Lung cancer
- 𧬠Prostate cancer
- π§ Primary brain tumours
- π©Έ Haematological malignancies
- π©Ί Pancreatic cancer
- π©ββοΈ Gynaecological cancers
π₯ Cancers Associated with Haemorrhagic Metastases
- π€ Melanoma
- π©Ί Renal cell carcinoma
- π§΅ Thyroid carcinoma
- π§« Germ cell tumours
βοΈ Aetiological Mechanisms
- Direct tumour vascular compression (arterial, venous, capillary).
- Procoagulant effects of malignancy or therapy.
- π§ͺ Leukostasis in leukaemia.
- Cardioembolism from marantic (non-infective) endocarditis.
- π‘ Radiation vasculopathy (esp. head/neck cancers).
- Overlap with classic vascular risks: HTN, diabetes, AF, smoking.
π¬ Mechanisms and Associated Tumours
- Hypercoagulability: adenocarcinomas (breast, lung, prostate, pancreas) β embolic infarcts.
- Venous-to-arterial embolism: via PFO in hypercoagulable states.
- NBTE (marantic endocarditis): sterile vegetations (aortic/mitral), esp. adenocarcinoma β multiple widespread strokes.
- Direct tumour compression: glioblastoma/metastases β MCA territory large strokes.
- Tumour embolism: atrial myxoma, cardiac metastasis.
- Hyperviscosity: myeloma, WaldenstrΓΆmβs, PV β small vessel strokes.
- Angioinvasion: lymphoma β multi-territory infarcts.
- Post-radiation vasculopathy: carotid stenosis after radiotherapy.
- Chemotherapy: e.g. cisplatin, methotrexate β variable mechanisms.
π©Ί Clinical Presentation
- Typical ischaemic syndromes or haemorrhagic strokes.
- Silent infarcts are common on MRI.
- DVT/PE alongside stroke strongly suggests cancer-related hypercoagulability.
β€οΈ Marantic Endocarditis (NBTE)
- Nonbacterial fibrinβplatelet vegetations on valves (aortic > mitral).
- Occurs in advanced malignancy, esp. adenocarcinoma.
- No infection β negative blood cultures.
- Echo (esp. TOE) may show vegetations.
- Leads to recurrent embolic strokes.
π Investigations
- π§ͺ Bloods: FBC, ESR, CRP, U&E, TFTs.
- π§ Neuroimaging: CT/MRI Β± contrast for infarct/haemorrhage/metastasis.
- π ECG (AF, arrhythmias).
- π Echocardiogram/TOE if NBTE suspected.
- π― Cancer staging where relevant.
π Differentials
- Other prothrombotic disorders (e.g. antiphospholipid).
- Primary CNS vasculitis.
π Management
- π₯ Shared care: Stroke, oncology, haematology teams collaborate.
- βοΈ Balance between stroke prevention and bleeding risk (esp. thrombocytopenia, metastases).
- π Anticoagulation: LMWH preferred (especially if marantic endocarditis).
- π‘οΈ VTE prophylaxis vital in immobile cancer patients.
- π― Tailor to cancer prognosis, patient wishes, and bleeding risk.
π References
π‘ Key Exam Pearl: Multiple embolic infarcts in different territories + raised D-dimer + weight loss β always think of occult cancer and consider NBTE.