Clinical study| Volume 57, P111-115, November 2018

Ability of the Khorana score to predict recurrent thromboembolism in cancer patients with ischemic stroke

Published:August 22, 2018DOI:


      • Khorana score has been shown to predict venous thromboembolism in cancer patients.
      • We aimed to test this score to predict recurrent thromboembolism (RTE) in cancer patients with ischemic stroke.
      • Khorana score was weakly associated with RTE in cancer patients with ischemic stroke, and did not accurately predict RTE.
      • Addition of other parameters such as D-dimer appears to improve the predictive accuracy of the score.


      Cancer patients with acute ischemic stroke (AIS) are high-risk for recurrent thromboembolic events (RTE). Currently, no risk stratification model exists to predict RTE in this population. We tested the hypothesis that the Khorana score, a validated risk model for predicting venous thromboembolism in cancer patients, can effectively classify RTE risk in cancer patients with AIS. We retrospectively identified adults with active solid or hematological cancer diagnosed with AIS at a tertiary-care cancer center from 2005 to 2010. The Khorana score at the time of index stroke was calculated. The primary outcome was arterial or venous RTE. Cox regression was used to evaluate the association of the Khorana score and its individual components with RTE. Harrell’s c-statistic was used to calculate the score’s discriminatory ability. Among 263 AIS patients, median survival was 84 days (IQR 24–149 days) and 90 (34%) had RTE. The median Khorana score was 2 (IQR 1–2, range 0–5). Cumulative rate of RTE was 28% among patients who scored 0, 36% with scores of 1–2, and 32% with scores of 3–6. The overall Khorana score was marginally associated with RTE (HR, 1.14; 95% CI, 1.02–1.28). Of its individual components, only leukocytosis was associated with RTE (HR adjusted for other components, 1.45; 95% CI 1.11–1.90). The score’s c-statistic for predicting RTE was 0.57. In this study, the Khorana score had poor discriminatory ability for predicting RTE in cancer patients with AIS. Future research is needed to identify better methods for predicting RTE in this high-risk population.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Clinical Neuroscience
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Navi B.B.
        • Reiner A.S.
        • Kamel H.
        • Iadecola C.
        • Elkind M.S.
        • Panageas K.S.
        • et al.
        Association between incident cancer and subsequent stroke.
        Ann Neurol. 2015; 77: 291-300
        • Blom J.W.
        • Doggen C.J.
        • Osanto S.
        • Rosendaal F.R.
        Malignancies, prothrombotic mutations, and the risk of venous thrombosis.
        JAMA. 2005; 293: 715-722
        • Gomes M.
        • Khorana A.A.
        Risk assessment for thrombosis in cancer.
        Semin Thromb Hemost. 2014; 40: 319-324
        • Bick R.L.
        Cancer-associated thrombosis.
        N Engl J Med. 2003; 349: 109-111
        • Prandoni P.
        • Falanga A.
        • Piccioli A.
        Cancer and venous thromboembolism.
        Lancet Oncol. 2005; 6: 401-410
        • Dammacco F.
        • Vacca A.
        • Procaccio P.
        • Ria R.
        • Marech I.
        • Racanelli V.
        Cancer-related coagulopathy (Trousseau's syndrome): review of the literature and experience of a single center of internal medicine.
        Clin Exp Med. 2013; 13: 85-97
        • Elliott A.
        • Wetzel J.
        • Roper T.
        • Pivalizza E.
        • McCarthy J.
        • Wallace C.
        • et al.
        Thromboelastography in patients with acute ischemic stroke.
        Int J Stroke. 2015; 10: 194-201
        • Navi B.B.
        • Reiner A.S.
        • Kamel H.
        • Iadecola C.
        • Okin P.M.
        • Elkind M.S.V.
        • et al.
        Risk of arterial thromboembolism in patients with cancer.
        J Am Coll Cardiol. 2017; 70: 926-938
        • Navi B.B.
        • Singer S.
        • Merkler A.E.
        • Cheng N.T.
        • Stone J.B.
        • Kamel H.
        • et al.
        Recurrent thromboembolic events after ischemic stroke in patients with cancer.
        Neurology. 2014; 83: 26-33
        • Khorana A.A.
        • Kuderer N.M.
        • Culakova E.
        • Lyman G.H.
        • Francis C.W.
        Development and validation of a predictive model for chemotherapy-associated thrombosis.
        Blood. 2008; 111: 4902-4907
        • Patell R.
        • Rybicki L.
        • McCrae K.R.
        • Khorana A.A.
        Predicting risk of venous thromboembolism in hospitalized cancer patients: utility of a risk assessment tool.
        Am J Hematol. 2017; 92: 501-507
        • Seok J.M.
        • Kim S.G.
        • Kim J.W.
        • Chung C.S.
        • Kim G.M.
        • Lee K.H.
        • et al.
        Coagulopathy and embolic signal in cancer patients with ischemic stroke.
        Ann Neurol. 2010; 68: 213-219
        • Lee A.Y.
        • Levine M.N.
        • Baker R.I.
        • Bowden C.
        • Kakkar A.K.
        • Prins M.
        • et al.
        Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer.
        N Engl J Med. 2003; 349: 146-153
        • Navi B.B.
        • Singer S.
        • Merkler A.E.
        • Cheng N.T.
        • Stone J.B.
        • Kamel H.
        • et al.
        Cryptogenic subtype predicts reduced survival among cancer patients with ischemic stroke.
        Stroke. 2014; 45: 2292-2297
        • Merkler A.E.
        • Navi B.B.
        • Singer S.
        • Cheng N.T.
        • Stone J.B.
        • Kamel H.
        • et al.
        Diagnostic yield of echocardiography in cancer patients with ischemic stroke.
        J Neurooncol. 2015; 123: 115-121
        • Guo Y.J.
        • Chang M.H.
        • Chen P.L.
        • Lee Y.S.
        • Chang Y.C.
        • Liao Y.C.
        Predictive value of plasma (D)-dimer levels for cancer-related stroke: a 3-year retrospective study.
        J Stroke Cerebrovasc Dis. 2014; 23: e249-e254
        • Mansfield A.S.
        • Tafur A.J.
        • Wang C.E.
        • Kourelis T.V.
        • Wysokinska E.M.
        • Yang P.
        Predictors of active cancer thromboembolic outcomes: validation of the Khorana score among patients with lung cancer.
        J Thromb Haemost. 2016; 14: 1773-1778
        • Tafur A.J.
        • Caprini J.A.
        • Cote L.
        • Trujillo-Santos J.
        • Del Toro J.
        • Garcia-Bragado F.
        • et al.
        Predictors of active cancer thromboembolic outcomes. RIETE experience of the Khorana score in cancer-associated thrombosis.
        Thromb Haemost. 2017; 117: 1192-1198
        • Abdel-Razeq H.
        • Mansour A.
        • Saadeh S.S.
        • Abu-Nasser M.
        • Makoseh M.
        • Salam M.
        • et al.
        The application of current proposed venous thromboembolism risk assessment model for ambulatory patients with cancer.
        Clin Appl Thromb Hemost. 2018 Apr; 24: 429-433
        • Ay C.
        • Dunkler D.
        • Marosi C.
        • Chiriac A.L.
        • Vormittag R.
        • Simanek R.
        • et al.
        Prediction of venous thromboembolism in cancer patients.
        Blood. 2010; 116: 5377-5382
        • Emerging Risk Factors C.
        • Kaptoge S.
        • Di Angelantonio E.
        • Lowe G.
        • Pepys M.B.
        • Thompson S.G.
        • et al.
        C-reactive protein concentration and risk of coronary heart disease, stroke, and mortality: an individual participant meta-analysis.
        Lancet. 2010; 375: 132-140
        • McEver R.P.
        Adhesive interactions of leukocytes, platelets, and the vessel wall during hemostasis and inflammation.
        Thromb Haemost. 2001; 86: 746-756
        • Bouchard B.A.
        • Tracy P.B.
        Platelets, leukocytes, and coagulation.
        Curr Opin Hematol. 2001; 8: 263-269