PracticeUpdate Neurology Best of 2018

CONFERENCE COVERAGE 22

Cancer Commonly ComorbidWith Stroke Clinicians should consider cancer as a cause of stroke among ischemic stroke patients. A s many as 10% of unselected stroke patients experience cancers comorbid with their con- ditions, according to a poster presented at AN 2018. Upon analyzing data from all ischemic stroke patients admitted to West Hertfordshire Hospital, in the United Kingdom, between July 2015 and June 2017, researcher David Collas, MBBS, consultant stroke physician at West Hertfordshire Hospitals NHS Trust, and colleagues determined that of the 1,317 patients included in the study, 9.7% also had a diagnosis of cancer. Notably, cancer was present in 7.6% of hemorrhagic stroke patients (12/212) and 10.1% of ischemic stroke patients (112/1105). A total of 8 patients experienced metastatic cancer; 7 patients experienced multiple cancers. In reviewing cases of comorbid cancer and stroke, the authors noted that resistance to standard anti-plate- let and anticoagulant therapy is common, leading to venous and arterial thromboses and vessel occlusions for these patients. “Thrombolysis was considered contraindicated in cancer,” said Dr. Collas, in an interview with Elsevier’s PracticeUpdate . “We found the chance of benefit and risk of hemorrhage are no different [in patients with comorbid cancer] than in other patients.” Cancers comorbid with stroke can cause stroke by a variety of mechanisms, including hypercoagulability, vascular involvement, and side effects of treatment modalities, including chemotherapy, radiotherapy, and procoagulant therapy, said the authors. “We were sur- prised, once we started looking, how the pattern of infarcts scattered through 2 or 3 vascular territories was characteristic, and a strong indicator that hypercoag- ulability or non-infectious endocarditis was the cause of the stroke,” said Dr. Collas. The researchers further suggest the presence of mul- tiple territory infarcts without a cardioembolic source (embolic stroke of uncertain source [ESUS]) may be indicative of a cancer-related stroke etiology, prompting the clinician to search for an occult cancer or implicate an existing cancer in the development of stroke. According to Dr. Collas, one important takeaway from the study was that “stroke could be the first sign of can- cer, and a search for cancer in cryptogenic stroke was important to uncover this.” In conclusion, Dr. Collas said clinicians should “treat stroke in the presence of cancer by thrombolysis where applicable, give more aggressive anti-thrombotic therapy, consider less thrombogenic chemotherapy regimens, and, where you find multiple territories affected by scattered infarcts, look for cancer if no other cause (such as atrial fibrillation) is present.” www.practiceupdate.com/c/67825

NewMethod of Monitoring Multiple Sclerosis Effective and 10 Times Less Expensive Than Conventional MRI Neurofilament light chains can be detected in blood test and used as a marker for treatment response, but method still needs validation. T he use of neurofilament light (NfL) chains could have a significant impact on how " If the NfL level is high, physicians can take action

physicians assess the effective- ness of treatment in patients with multiple sclerosis (MS), according to research presented at AAN 2018. “This could change the way MS is treated. It is now proving its use- fulness in individual patients,” Jens Kuhle, MD, of the University of Basel in Switzerland, told Elsevier’s PracticeUpdate . “It’s all about measuring nerve health… Just imagine if you could measure in a blood test how your nervous system is doing,” he added. NfL chains are unique to neuronal cells and are shed into the cer- ebrospinal fluid (CSF). They are detectable at low concentrations in peripheral blood. Various diseases causing neuronal damage, including MS, have resulted in elevated CSF concentrations of NfL chains. “The NfL chain in blood samples is a pri- mary marker of treatment response or nonresponse. It is a good bio- marker for investigating new drugs as well,” said Dr. Kuhle. In a study published last year in the Annals of Neurology , Dr. Kuhle and his colleagues demonstrated the value of an ultrasensitive sin- gle-molecule array (Simoa) serum NfL (sNfL) assay in healthy controls and two independent MS cohorts: (1) cross-sectional with paired serum and CSF samples and (2) longitudi- nal with repeated serum sampling. There was a median follow-up time of 3 years. The relation of the assay to concurrent clinical, imaging, and treatment parameters and to future clinical outcomes was assessed. sNfL levels were higher in both MS cohorts than in the control group. Patients with either brain or spinal or both brain and spinal gadolini- um-enhancing lesions had higher

sNfL levels than those without. Gen- erally, noted Dr. Kuhle, there are increasingly higher levels of sNfLs in the blood when MS patients have a relapse. “Those with higher levels in their blood fare worse over the next 2 to 5 years.” The use of NfL as a biomarker fills a “major unmet need, especially in the MS field,” he added. “If the NfL level is high, physicians can take action to bring it down. If the treatment works, the measure is low. If the NfL is high, you should choose another drug.” Determining NfL levels is a rela- tively inexpensive option. Although a large piece of specialized equip- ment, about the size of a small car, is needed to determine NfL levels, the cost per test is 10 times less expensive than the use of an MRI, the standard means of following MS progression. Analytical validation of the meth- odology is ongoing to determine its reliability. At present, noted Dr. Kuhle, MRI and clinical assessments do not correlate with NfL levels. “This will need to be shown to be reliable before moving to a stage where this is a main test.” Age-dependent reference values are also needed to help set param- eters for what constitutes a normal to bring it down. If the treatment works, the measure is low. If the NfL is high, you should choose another drug. "

and high range of results. www.practiceupdate.com/c/67334

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