Clinical and Translational Neuroscience Unit, Feil Family and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY.
Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA.
J Stroke Cerebrovasc Dis. 2020 Dec;29(12):105366. doi: 10.1016/j.jstrokecerebrovasdis.2020.105366. Epub 2020 Oct 8.
Patients with acute ischemic stroke associated with cancer have D-dimer elevations greater than those with acute ischemic stroke or cancer alone. While D-dimer has been proposed as a screening tool to identify such patients, its use in clinical practice to identify malignancy and to inform the use of CT scanning has not been well characterized.
We conducted a retrospective cohort study of patients with acute ischemic stroke to evaluate how D-dimer levels and CT chest, abdomen, and pelvis scanning were used in practice to screen for occult malignancy. Patients were excluded if they had known active cancer and or received tPA.
Of 480 patients, 254 (53%) had D-dimer measured, 49 (10%) underwent CT screening for cancer, and 11 (2%) had findings concerning for malignancy. There was no difference in D-dimer level between patients who underwent CT evaluation for cancer and those who did not (median 1.01 vs 0.85 p = 0.19). Patients with CT concerning for cancer had higher D-dimer levels than those with a negative CT (median 2.52 vs 0.74 p = 0.01). D-dimer demonstrated moderate discrimination with a c-statistic of 0.77. Selecting a cut point of >1.2 ug/mL (60 percentile of our cohort and 2.4-times the upper limit of normal for our institution's D-dimer assay) provided a sensitivity of 85% and specificity of 65%, a positive likelihood ratio of 2.32, and an odds ratio of 9.6 (95% confidence interval 2.1-44.1, p = 0.004) for having a CT scan concerning for malignancy.
Elevated D-dimer levels are suggestive of occult malignancy in acute ischemic stroke patients and should inform selective use of CT to screen for cancer.
伴有癌症的急性缺血性脑卒中患者的 D-二聚体升高幅度大于单纯急性缺血性脑卒中或癌症患者。虽然 D-二聚体已被提议作为一种筛查工具来识别此类患者，但它在临床实践中用于识别恶性肿瘤并告知 CT 扫描的使用尚未得到很好的描述。
我们对急性缺血性脑卒中患者进行了回顾性队列研究，以评估 D-二聚体水平以及 CT 胸部、腹部和骨盆扫描在实践中如何用于筛查隐匿性恶性肿瘤。如果患者有已知的活动性癌症或接受 tPA 治疗，则将其排除在外。
在 480 名患者中，254 名（53%）测量了 D-二聚体，49 名（10%）进行了癌症 CT 筛查，11 名（2%）有恶性肿瘤的发现。接受癌症 CT 评估的患者与未接受 CT 评估的患者的 D-二聚体水平无差异（中位数 1.01 对 0.85，p=0.19）。CT 检查结果为癌症的患者的 D-二聚体水平高于 CT 检查结果为阴性的患者（中位数 2.52 对 0.74，p=0.01）。D-二聚体的判别能力中等，C 统计量为 0.77。选择>1.2μg/mL（我们队列的第 60 百分位数和我们机构 D-二聚体检测的上限的 2.4 倍）的切点可提供 85%的敏感性和 65%的特异性、2.32 的阳性似然比和 9.6 的比值比（95%置信区间为 2.1-44.1，p=0.004），提示 CT 扫描有恶性肿瘤的可能性。
急性缺血性脑卒中患者中升高的 D-二聚体水平提示隐匿性恶性肿瘤，应告知选择性使用 CT 筛查癌症。
