Acute reperfusion treatment and secondary prevention of cancer-related stroke: comprehensive overview and proposal of clinical algorithm

Long-term outcomes of mechanical thrombectomy in acute ischaemic stroke patients with concomitant malignancy

Introduction

Patients with cancer (CP) need a different approach to acute ischaemic stroke (AIS) treatment as intravenous thrombolysis (IVT) may be contraindicated. Mechanical thrombectomy (MT) is a treatment of choice for otherwise eligible patients, although the literature on its long-term outcomes in CP is limited.

Aim

Assessing outcomes of MT-treated AIS patients with concomitant malignancy in a year-long follow-up.

Material and methods

The study included 593 MT-treated AIS patients admitted in 2019-2021. The group was divided into CP (defined as a diagnosis of malignancy and undergoing/qualified for cancer treatment within previous 5 years) and a control group. The profile of cardiovascular risk factors, stroke severity and discharge, 90-day and 365-day outcomes were compared between the groups.

Results

CP and controls had a similar profile of cardiovascular risk factors and comparable stroke severity. CP were less frequently treated with IVT (25.7% vs. 59.1%, p < 0.001). There were no differences between the groups in the successful reperfusion rate and occurrence of haemorrhagic complications. Discharge and 90-day outcomes were similar. CP had higher 365-day mortality (48.6% vs. 29.9%, p = 0.024) but the percentage of patients achieving good functional outcome in a year-long observation was comparable.

Conclusions

Treatment with MT seems beneficial for AIS patients with concomitant malignancy both in short- and long-term observation.

A Single-Center Experience of Mechanical Thrombectomy for Cancer-Associated Ischemic Stroke

Objectives

Cancer-associated ischemic stroke tends to extend over multiple vascular territories and develops under poor general conditions. Owing to the rarity of such cases and poor prognoses, no comprehensive studies on mechanical thrombectomy for cancer-associated ischemic stroke have been reported in Japan. The present study investigated the radiological and clinical characteristics of mechanical thrombectomy in patients with cancer-associated ischemic stroke at our institution.

Methods

We retrospectively reviewed 108 patients who underwent mechanical thrombectomy for large cerebral artery occlusion between January 1, 2021, and October 31, 2022, at our institution. The characteristics of mechanical thrombectomy in the cancer-associated ischemic stroke group were compared with those in the control group.

Results

Of the 108 patients (112 procedures), seven patients (eight procedures) with clinically diagnosed cancer-associated ischemic stroke underwent mechanical thrombectomy. Of the eight procedures, six were performed during hospitalization. In contrast, only 10 of 104 procedures were performed in the control group. The in-hospital onset rate was higher in the cancer-associated ischemic stroke group (75.0%) compared to that in the controls (9.6%); p <0.001. The puncture-to-reperfusion time was significantly longer in the cancer-associated ischemic stroke group in comparison to that in the controls with a median interquartile range of 69 minutes (60.0-82.0 minutes) and 59.5 minutes (44.5-69.3 minutes), respectively (p <0.01). However, the rates of successful recanalization defined as thrombolysis in cerebral infarction ≥2b were not significantly different between the cancer-associated ischemic stroke group and controls with values of 62.5% and 79.8%, respectively (p = 0.250). Of the eight cases in the cancer-associated ischemic stroke group, only one (12.5%) had a good outcome on a modified Rankin Scale score of 0 to 2 at discharge, in contrast to 23 of the 104 (23.1%) cases in the controls (p = 0.523). Histopathological examination of six retrieved thrombi in the cancer-associated stroke group using hematoxylin and eosin staining revealed that only one case showed an erythrocyte-dominant thrombus while five displayed a fibrinoplatelet-dominant component. Conversely, 65 of 92 retrieved thrombi in the control group were erythrocyte dominant. Cancer was pathologically diagnosed in four of seven patients, all of which were adenocarcinomas.

Conclusion

Cancer-associated ischemic stroke tends to occur during hospitalization. Coagulation disorders associated with cancer, especially adenocarcinoma, may be related to the formation of thrombi with fibrinoplatelet-dominant components, leading to ischemic stroke. The procedural time for mechanical thrombectomy in cancer-associated ischemic stroke tends to be longer.

Treatment of acute ischemic stroke in patients with active malignancy: insight from a comprehensive stroke center

Background

Despite the high incidence of acute ischemic stroke (AIS) in cancer patients, there is still no consensus about the safety of recanalization therapies in this cohort.

Objectives

In this observational study, our aim was to investigate the bleeding risk after acute recanalization therapy in AIS patients with active malignancy.

Methods and Study Design

We retrospectively analyzed observational data of 1016 AIS patients who received intravenous thrombolysis with rtPA (IVT) and/or endovascular therapy (EVT) between January 2017 and December 2020 with a focus on patients with active malignancy. The primary safety endpoint was the occurrence of stroke treatment-related major bleeding events, that is, symptomatic intracranial hemorrhage (SICH) and/or relevant systemic bleeding. The primary efficacy endpoint was neurological improvement during hospital stay (NI).

Results

None of the 79 AIS patients with active malignancy suffered from stroke treatment-related systemic bleeding. The increased rate (7.6% versus 4.7%) of SICH after therapy compared to the control group was explained by confounding factors. A total of nine patients with cerebral tumor manifestation received acute stroke therapy, two of them suffered from stroke treatment-related intracranial hemorrhage remote from the tumor, both asymptomatic. The group of patients with active malignancy and the control group showed comparable rates of NI.

Conclusion

Recanalization therapy in AIS patients with active malignancy was not associated with a higher risk for stroke treatment-related systemic or intracranial bleeding. IVT and/or EVT can be regarded as a safe therapy option for AIS patients with active malignancy.