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We are thankful to Lonergan and his colleagues for reporting this very interesting case of stroke that has been linked to sunitinib therapy. I have a few notes:
1. The very first thing is the age of the patient? How old is he?
2. The author did mention that the patient had several risk factors for ischaemic stroke, but he linked this stroke mainly to sunitinib. What evidence points...
2. The author did mention that the patient had several risk factors for ischaemic stroke, but he linked this stroke mainly to sunitinib. What evidence points to sunitinib as the potential culprit? Does the negative work-up for an embolic source suffice? Tumor cells may embolize as well.
3. The MRI image suggests a right hemispheric infarction in the territory of the right middle cerebral artery; most likely, the main stem is occluded rather than the posterior inferior branch. Occlusion of either of these is usually embolic, and the work-up was directed properly to this. The given image is the T2 FLAIR, not the T2. The peri-ventricular white matter hyper-intense lesions seen in this image (which were not suppressible on the T2 FLAIR) are compatible with small vessel disease. These lesions are strong indicators of the presence of long-standing hypertension.
Kunitz and Foulkes and their co-workers at the National Institute of Neurologic Disease and Stroke (NINDS) Stroke Data Bank were the first to use the term cryptogenic stroke [1,2]; this was in the mid 80s. Several years later, the TOAST investigators modified this term to "stroke of
undetermined origin" and further categorized it .
The TOAST defines this "stroke of undetermined origin" as brain infarction that is not attributable to a source of definite cardio-embolism, large artery atherosclerosis, or small artery disease despite extensive vascular, cardiac, and serologic evaluation. This form of ischaemic stroke forms about 30-40% of all ischaemic strokes [4-6].
It is well known that malignancy is a hypercoagulable state; this, together with the "old" age of the patient, hypertension, and smoking would put the patient at risk of developing a vascular incidence/event. The common is
Depending simply on the negative imaging studies for an embolic source to mark sunitinib as the likely cause behind this stroke might be reasonable in a young patient with no atherosclerosis/vascular risk factors.
1. Kunitz SC, Gross CR, Heyman A, et al. The pilot Stroke Data Bank: definition, design, and data. Stroke 1984; 15:740.
2. Foulkes MA, Wolf PA, Price TR, et al. The Stroke Data Bank: design, methods, and baseline characteristics. Stroke 1988; 19:547.
3. Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial. Stroke 1993; 24:35.
4. Sacco RL, Ellenberg JH, Mohr JP, et al. Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Ann Neurol 1989; 25:382.
5. Petty GW, Brown RD, Whisnant JP, et al. Ischemic stroke subtypes: A population-based study of incidence and risk factors. Stroke 1999; 30:2513.
6. Kolominsky-Rabas PL, Weber M, Gefeller O, et al. Epidemiology of ischemic stroke subtypes according to TOAST criteria: incidence, recurrence, and long-term survival in ischemic stroke subtypes: a population-based study. Stroke 2001; 32:2735.