Objectives: Ischemic stroke and concurrent cancer is increasingly recognized. However, optimal management is uncertain. As mechanical thrombectomy has become the standard of care for large vessel occlusion, more patients with cancer are presenting for embolectomy. However, it is unknown whether this subgroup has the same benefit profile described in multiple randomized trials for thrombectomy for large vessel occlusion. Our objective was to retrospectively evaluate a North American embolectomy database for safety and outcomes in patients with active cancer. Materials and methods: A case series of 284 embolectomies over 30 months at a single North American stroke center were divided into thrombectomy patients with active cancer(n=25) and those without active cancer (n=259). We compared patient characteristics, procedural characteristics, and procedural outcomes between patients with and without active cancer. Univariate and multivariate analysis of angiographic outcomes, postoperative hemorrhage, and functional outcome was performed. Results: Of the 284 thrombectomy cases, 9% were performed on patients with active cancer. Active cancer patients had a similar recanalization grade and post-operative hemorrhage rate, compared to patients without cancer. Active cancer patients had a significantly higher 90 day mortality (40% vs 20%, p=0.018). On multivariate analysis, good functional outcome (mRS 0-2) was not impacted by active cancer. However, when mRS was evaluated as an ordinal shift analysis, worse functional outcome was associated with active cancer (OR 2.98; 95% CI, 1.29 to 6.59), greater age, NIHSS> 10, and ASPECTS<9. Conclusions: This single center retrospective series of active cancer patients undergoing thrombectomy for large vessel occlusion demonstrates similar rates of recanalization, post-operative hemorrhage, and good outcomes. While the active cancer group has a high short-term mortality, the potential to maintain quality of life in the survivors makes thrombectomy reasonable in this patient population. Awareness of ischemic stroke as a complication of cancer and the safety of thrombectomy in this population are important as this population subtype is expected to grow with improved oncology and stroke care

Introduction Narrative approaches to assessment provide meaningful and valid representations of trainee performance. Yet, narratives are frequently perceived as vague, nonspecific and low quality. To date, there is little research examining factors associated with narrative evaluation quality, particularly in undergraduate medical education. The purpose of this study was to examine associations of faculty- and student-level characteristics with the quality of faculty member's narrative evaluations of clerkship students. Methods The authors reviewed faculty narrative evaluations of 50 students' clinical performance in their inpatient medicine and neurology clerkships, resulting in 165 and 87 unique evaluations in the respective clerkships. The authors evaluated narrative quality using the Narrative Evaluation Quality Instrument (NEQI). The authors used linear mixed effects modelling to predict total NEQI score. Explanatory covariates included the following: time to evaluation completion, number of weeks spent with student, faculty total weeks on service per year, total faculty years in clinical education, student gender, faculty gender, and an interaction term between student and faculty gender. Results Significantly higher narrative evaluation quality was associated with a shorter time to evaluation completion, with NEQI scores decreasing by approximately 0.3 points every 10 days following students' rotations (p = .004). Additionally, women faculty had statistically higher quality narrative evaluations with NEQI scores 1.92 points greater than men faculty (p = .012). All other covariates were not significant. Conclusions The quality of faculty members' narrative evaluations of medical students was associated with time to evaluation completion and faculty gender but not faculty experience in clinical education, faculty weeks on service, or the amount of time spent with students. Findings advance understanding on ways to improve the quality of narrative evaluations which are imperative given assessment models that will increase the volume and reliance on narratives.

Background and Purpose— Protease/antiprotease imbalance is implicated in the pathogenesis of emphysema and may also lead to vessel wall weakening, aneurysm development, and rupture. However, it is unclear whether emphysema is associated with cerebral and aortic aneurysm rupture. Methods— We performed a retrospective cohort study using outpatient and inpatient claims data from 2008 to 2014 from a nationally representative sample of Medicare beneficiaries ≥66 years of age. Our predictor variable was emphysema, and our outcome was hospitalization for either aneurysmal subarachnoid hemorrhage or a ruptured aortic aneurysm. All predictors and outcomes were defined using previously reported International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithms. Survival statistics and Cox regression were used to compare risk between patients with and without emphysema. Results— We identified 1 670 915 patients, of whom 133 972 had a diagnosis of emphysema. During a mean follow-up period of 4.3 (±1.9) years, we identified 4835 cases of aneurysm rupture, 433 of which occurred in patients with emphysema. The annual incidence of aneurysm rupture was 6.5 (95% CI, 6.4–6.8) per 10 000 in patients without emphysema and 14.6 (95% CI, 13.3–16.0) per 10 000 in patients with emphysema. After adjustment for demographics and known risk factors for aneurysmal disease, emphysema was independently associated with aneurysm rupture (hazard ratio, 1.7; 95% CI, 1.5–1.9). Emphysema was associated with both aneurysmal subarachnoid hemorrhage (hazard ratio, 1.5; 95% CI, 1.3–1.7) and ruptured aortic aneurysm (hazard ratio, 2.3; 95% CI, 1.9–2.8). Conclusions— Patients with emphysema face an increased risk of developing subarachnoid hemorrhage and aortic aneurysm rupture, potentially consistent with shared pathways in pathogenesis.

OBJECTIVE:We sought to characterize the US nationwide temporal trends in recanalization therapy utilization for ischemic stroke among patients with and without cancer.METHODS:We identified all acute ischemic stroke (AIS) hospitalizations in the National Inpatient Sample from January 1, 1998 to September 30, 2015. The primary exposure was solid or hematologic cancer. The primary outcome was use of intravenous thrombolysis. The secondary outcome was use of endovascular therapy (EVT).RESULTS:Among 9,508,804 AIS hospitalizations, 503,510 (5.3%) involved cancer patients. Intravenous thrombolysis use among ischemic stroke patients with cancer increased from .01% (95% confidence interval [CI], .00%-.02%) in 1998 to 4.91% (95% CI, 4.33%-5.48%) in 2015, whereas intravenous thrombolysis use among ischemic stroke patients without cancer increased from .02% (95% CI, .01%-.02%) in 1998 to 7.22% (95% CI, 6.98%-7.45%) in 2015. The demographic- and comorbidity-adjusted odds ratio/year of receiving intravenous thrombolysis was similar in patients with cancer (1.21; 95% CI, 1.20-1.23) versus those without (1.20; 95% CI, 1.19-1.21). EVT use among ischemic stroke patients with cancer increased from .05% (95% CI, .02%-.07%) in 2006 to 1.90% (95% CI, 1.49%-2.31%) in 2015, whereas EVT use among ischemic stroke patients without cancer increased from .09% (95% CI, .00%-.18%) in 2006 to 1.88% (95% CI, 1.68%-2.09%) in 2015.CONCLUSIONS:Among 9.5 million AIS hospitalizations, patients with cancer received intravenous thrombolysis about two thirds as often as patients without cancer. This difference persisted over time despite increased utilization in both groups. EVT utilization was similar between cancer and non-cancer AIS patients.

Background: Whether cancer patients receive acute recanalization therapies as often as non-cancer patients with acute ischemic stroke (AIS) is uncertain. Additionally, while use of recanalization therapies for AIS have increased over time, it is unknown whether similar trends have occurred among stroke patients with cancer. Methods: Using ICD-9 diagnosis codes, we identified all patients hospitalized with AIS in the National Inpatient Sample (NIS) from 1998-2013. Our primary predictor was systemic cancer, which was a composite of solid and hematologic tumors with or without metastases. Primary brain tumors were excluded. Our primary outcome was use of intravenous tissue plasminogen activator (IV-tPA). Our secondary outcome was use of endovascular therapy (EVT). Annual estimates of nationwide recanalization therapy use were calculated. Results: Among 8.5M patients with AIS, 439,905 (5.2%) had cancer. The rate of IV-tPA use among AIS patients with cancer increased from 0.01% (95% CI 0.00-0.02%) in 1998 to 4.23% (95% CI 3.72-4.75%) in 2013; while the rate of IV-tPA use among AIS patients without cancer increased from 0.02% (95% CI 0.01-0.02%) in 1998 to 6.38% (95% CI 6.16-6.61%) in 2013 (Figure). The demographic-adjusted odds ratio per year of receiving IV-tPA was similar in patients with cancer (1.21; 95% CI 1.20-1.23) and in those without (1.20; 95% CI 1.19-1.21). The rate of EVT use among AIS patients with cancer increased from 0.05% (95% CI 0.02-0.07%) in 2006 (no procedures reported in NIS before then) to 1.07% (95% CI 0.81-1.33%) in 2013; while the rate of EVT use among AIS patients without cancer increased from 0.09% (95% CI 0.00-0.18%) in 2006 to 1.09% (95% CI 0.95-1.22%) in 2013. Conclusion: Cancer patients with AIS receive IV-tPA about two-thirds as often as non-cancer patients with AIS and this disparity has persisted over time despite increased utilization rates in both groups. Use of endovascular therapy is similar between cancer and non-cancer AIS patients.

Background: About 5% of acute ischemic stroke (AIS) patients have active cancer. Previous work has shown that cancer patients are more likely to die after AIS than non-cancer patients. However, few data exist on how these disparities are changing over time. Methods: We identified all patients hospitalized with AIS in the National Inpatient Sample from 1996-2013 using validated ICD-9 diagnosis codes. Our primary predictor was systemic cancer, which was a composite of solid and hematologic tumors with or without metastases. Primary brain tumors were excluded. Our primary outcome was in-hospital death. Survey weights were used to estimate nationally-representative annual rates of in-hospital death among AIS patients with and without cancer. Multivariable logistic regression models adjusting for age, gender, and race were constructed to evaluate the relationship between time, cancer history, and mortality. Results: We identified 9.6 million patients with AIS, of whom 491,704 (5.1%) had cancer. The in-hospital death rate among stroke patients with cancer decreased from 21.7% (95% confidence interval [CI], 20.6-22.9%) in 1996 to 13.9% (95% CI, 13.0-14.7%) in 2013, while the death rate among stroke patients without cancer decreased from 9.9% (95% CI, 9.6-10.1%) in 1996 to 6.4% (95% CI, 6.2-6.6%) in 2013 (Figure). After adjustment for demographics, a cancer diagnosis was associated with more than a doubling in odds of death after AIS (odds ratio [OR] 2.34; 95% CI, 2.29-2.38). However, during the 18-year study period, the demographic-adjusted odds of in-hospital death after AIS decreased similarly over time in patients with cancer (OR per year 0.97; 95% CI, 0.96-0.97) as compared to those without (OR per year 0.97; 95% CI, 0.97-0.98). Conclusions: Despite improved mortality rates over time, cancer patients with AIS continue to face more than a two-fold increased risk of in-hospital death as compared to non-cancer AIS patients.

BACKGROUND:Stroke mechanisms and the risk of recurrent thromboembolism are incompletely understood in patients with primary brain tumors. We sought to better delineate these important clinical features.METHODS:We performed a retrospective cohort study of adults with primary brain tumors diagnosed with magnetic resonance imaging-confirmed acute ischemic stroke at the Memorial Sloan Kettering Cancer Center from 2005 to 2015. Study neurologists collected data on patients' cancer history, stroke risk factors, treatments, and outcomes. Stroke mechanisms were adjudicated by consensus. The primary outcome was recurrent thromboembolism (arterial or venous) and the secondary outcome was recurrent ischemic stroke. Kaplan-Meier statistics were used to calculate cumulative outcome rates, and Cox hazards analysis was used to evaluate the association between potential risk factors and outcomes.RESULTS:We identified 83 patients with primary brain tumors and symptomatic acute ischemic stroke. Median survival after index stroke was 2.2 years (interquartile range, .5-7.0). Tumors were mostly gliomas (72%) and meningiomas (13%). Most strokes were from unconventional mechanisms, particularly radiation vasculopathy (36%) and surgical manipulation (18%). Small- or large-vessel disease or cardioembolism caused 13% of strokes, whereas 29% were cryptogenic. Cumulative recurrent thromboembolism rates were 11% at 30 days, 17% at 180 days, and 27% at 365 days, whereas cumulative recurrent stroke rates were 5% at 30 days, 11% at 180 days, and 13% at 365 days. We found no significant predictors of outcomes.CONCLUSION:Patients with primary brain tumors generally develop strokes from rare mechanisms, and their risk of recurrent thromboembolism, including stroke, is high.

Introduction: Patients with systemic cancer often develop acute ischemic stroke from unique mechanisms, including cancer-mediated hypercoagulability, and their risk of recurrence is high. Conversely, stroke mechanisms in patients with primary brain tumors are incompletely understood, and the risk of recurrent thromboembolism in these patients is uncertain. Methods: We performed a retrospective cohort study of adult patients treated for a primary brain tumor at Memorial Sloan Kettering Cancer Center who were diagnosed with MRI-confirmed acute ischemic stroke from 2005 to 2015. Study neurologists used all available electronic records to collect data on patients’ cancer history, stroke risk factors, treatments, and outcomes. Stroke mechanisms, including the TOAST stroke subtype classification, were adjudicated by consensus. The primary outcome was recurrent thromboembolism (arterial or venous) and the secondary outcome was recurrent ischemic stroke. Kaplan-Meier survival statistics were used to calculate cumulative outcome rates, and multivariate Cox proportional hazards analysis was used to evaluate the association between several prespecified potential risk factors and outcomes. Results: We identified 83 patients with primary brain tumors and acute ischemic stroke. Median age was 60 years (IQR 51-67) and 53% were women. Tumors were mostly gliomas (72%) and meningiomas (13%). Prior head and neck radiotherapy was common (71%). Most strokes were from unconventional mechanisms, particularly radiation vasculopathy (36%) and surgical manipulation (19%). Small- or large-vessel disease or cardioembolism caused 13% of strokes, while 28% were cryptogenic. Median survival from index stroke was 2.2 years. Cumulative rates of recurrent thromboembolism were 11% at 30 days, 17% at 180 days, and 27% at 360 days; while cumulative rates of recurrent stroke were 5% at 30 days, 8% at 180 days, and 13% at 360 days. We found no significant predictors of outcomes, although radiation vasculopathy was nonsignificantly associated with recurrent stroke (HR 2.4, 95% CI 0.7-7.8). Conclusions: Patients with primary brain tumors generally develop strokes from unique mechanisms and their risk of recurrence is high.