Ischemic stroke: A paradoxical manifestation of cancer.

INTRODUCTION: Approximately 5-10 % of the patients with cryptogenic stroke have an underlying malignancy. Stroke as a complication of cancer increases the morbidity and mortality among cancer patients, leading to increased disability and healthcare costs. OBJECTIVE: To provide elements to guide physicians for when to suspect and evaluate for cancer in stroke patients. DEVELOPMENT: We performed a narrative review, portrayed in a question-answer format, to report relevant aspects of cancer stroke patients in the clinical practice and provide a guide based on the state-of-the-art literature. Conventional stroke mechanisms are only found in a fraction of patients with cancer. Although cardiovascular risk factors play an important role in both cancer and stroke pathogenesis, the recognition of more specific cancer-associated risk factors raises clinical suspicion for occult malignancy. We also expose the main type location and histology of tumors that are most commonly associated with stroke as well as potential blood biomarkers and current treatment considerations in the scenario of cancer associated stroke. CONCLUSION: Subjects with active cancer are a patient population at increased risk for developing an ischemic stroke. Cryptogenic stroke patients have a higher risk of cancer diagnosis in the following 6-12 months. We recommend a multidisciplinary approach considering the high probability of a hidden malignancy and running a comprehensive evaluation including neurologic imaging, serological biomarkers and tight follow up.

Fatal reversible cerebral vasoconstriction syndrome: A systematic review of case series and case reports.

OBJECTIVE: To describe patient characteristics, radiological findings and the clinical course of adults with fatal reversible cerebral vasoconstriction syndrome (RCVS). METHODS: A systematic literature search from January 1, 2000, until December 31, 2018, was performed using PubMed, EMBASE, Scopus, Cochrane reviews, LILACS and Scielo. Studies reporting RCVS in adult patients with fatal outcomes were included. RESULTS: 430 studies were initially identified, 179 full-text articles were reviewed, and 9 publications describing 12 subjects were included. The vast majority of the reports were from the U.S. Most of the female cases occurred during postpartum. All patients had a headache on initial presentation, although only 42% had thunderclap headache. A CT scan was performed on 67% of the patients. Imaging results were diverse, with a tendency toward cerebral hemorrhage followed by mixed cases. The main course of treatment included steroids (58% of the patients), with only 42% receiving nimodipine. The time to death ranged from 4 to 14 days, with a median of 9.2 days (SD ±â€¯3.2). CONCLUSION: We found that the majority of fatal cases reported in the literature are most likely related to postpartum angiopathy. We established a tendency in the onset of brain hemorrhage and the combination of infarction and brain hemorrhage. We described various markers for poor prognosis, including focal signs, the presence of hemorrhage and infarct in the first diagnostic image obtained and the need for invasive interventions. The majority of fatal cases in our report occurred in women, with over half of those cases during the puerperium period.

Factores relacionados con desenlace adverso para ataque cerebrovascular en un hospital de Bogotá. Estudio de casos y controles / Factors related to an adverse outcome for stroke in a Bogota hospital. Case-control study

RESUMEN OBJETIVOS: Determinar los factores de riesgo para resultado adverso entre los pacientes con ataque cerebrovascular (ACV) isquémico agudo. MATERIALES Y MÉTODOS: Se realizó un estudio retrospectivo de casos y controles. Se analizaron pacientes con un desenlace adverso al egreso con una escala de Rankin modificada mayor o igual a 3, contra los pacientes con un desenlace calificado como favorable por una escala menor o igual a 2. Se compararon los 2 grupos para determinar los factores que podrían estar relacionados con un desenlace adverso. Como desenlace secundario se analizaron los factores de riesgo asociados con mortalidad intrahospitalaria. En cuanto a las técnicas estadísticas, se realizó un análisis univariado y otro multivariado por regresión logística, con ajuste por variables como la edad y la severidad, medidas por la escala de NIHSS, conocidos previamente como factores de riesgo para desenlace adverso. RESULTADOS: Los factores de riesgo relacionados con un desenlace adverso entre los pacientes con ACV isquémico agudo fueron los antecedentes de hipertensión arterial, fibrilación auricular, la etiología cardioembólica y el hecho de ser candidato a trombolisis. Como factor protector se encontró la rápida mejoría. CONCLUSIONES: Los factores de riesgo encontrados en el estudio para desenlace adverso en ACV isquémico agudo son similares a los descritos previamente, aunque estos se han relacionado con desenlace en general, no solo para la entidad analizada.

SUMMARY OBJECTIVES: Determining risk factors for adverse outcome among acute ischemic stroke patients. METHODS: Retrospective case-control study. We compared two groups of patients: the first one with bad outcome after ischemic stroke (Modified Ranking Scale >3) and the second one with good outcome (Modified Ranking Scale <2) to find the risk factors that contributed to the complications. The secondary outcome observed was the in-hospital mortality risk factors. Statistics: univariate and multivariate analysis was made adjusted to age and severity using NIHSS and logistic regression. RESULTS: High blood pressure, atrial fibrillation, cardioembolic etiology and thrombolysis were identified as risk factors for bad outcome. The rapidly improving stroke proved to be a protective factor. CONCLUSION: Risk factors were similar to the ones known in the general group of stroke, proving they are similar in the group with acute stroke.

Prevalencia de infarto criptogénico en pacientes con diagnóstico de infarto cerebral / Prevalence of cryptogenic stroke in patients with a diagnosis of cerebral infarction

Resumen Objetivo: Definir la prevalencia del infarto de origen criptogénico en pacientes con diagnóstico de infarto cerebral isquémico entre los años 2007 a 2014. Métodos: Se realizó un estudio de tipo corte transversal. Se incluyeron todos los pacientes mayores de 18 años con ataque cerebrovascular isquémico agudo. Se evaluó cada caso mediante una lista de chequeo para la etiología y los estudios de cardiología. Se hizo una descripción de la población y de los factores de riesgo con análisis univariado. La asociación de los criptogénicos y no criptogénicos con las diferentes exposiciones se evaluó con el uso de Chi2 o T de Student de acuerdo con el tipo de variable. Se calcularon las razones de disparidad para los factores de riesgo. Se hizo un análisis multivariado para las variables independientes con p < 0,1. Resultados: en 340 pacientes se encontró una prevalencia de evento cerebrovascular Criptogénico del 19,71% (n = 67). Al dicotomizar la edad se observó que la prevalencia de ataque cerebrovascular criptogénico fue mayor en el grupo de <45 años 42,31% vs. 17,83% ≥45 años (p = 0,003), con una razón de prevalencias de 2,37. Solo la enfermedad coronaria (p = 0,04) y la fibrilación auricular (p < 0,0001), se relacionaron con los casos no criptogénicos en el modelo multivariado. Conclusiones: se halló una prevalencia de infarto criptogénico ligeramente inferior a la encontrada en la literatura reciente, que pudiera explicarse por un estudio más profundo en nuestra población o un subregistro de la enfermedad.

Abstract Objective: To define the prevalence of cryptogenic stroke in patients with a diagnosis of ischemic cerebral infarction between 2007 and 2014. Methods: A cross-sectional study was performed that included all patients over the age of 18 who had suffered an acute ischemic stroke. Each case was evaluated using a checklist for aetiology and cardiology studies. A description was made of the population and the risk factors with univariate analysis. The association with different exposures of cryptogenic and non-cryptogenic stroke was evaluated using the Chi2 or Student's t-test according to the type of variable. The disparity ratios were calculated for the risk factors. A multivariate analysis was undertaken for the independent variables with p < 0.1. Results: a prevalence of 19.71% (n = 67) of cryptogenic stroke was found in 340 patients. When dichotomising age it was observed that the prevalence of cryptogenic stroke was greater in the <45 age group, 42.31% vs 17.83% in the ≥45 age group (p = 0.003), with a prevalence ratio of 2.37. Only coronary heart disease (p = 0.04) and atrial fibrillation (p < 0.0001), were associated with the non-cryptogenic cases in the multivariate model. Conclusions: a slightly lower prevalence of cryptogenic stroke was found than that described in the recent literature. This could be explained by a more in-depth study in our population or under-reporting of the disease.