Endovascular Therapy is Effective for Large Vessel Occlusion Despite Concurrent Cancer

Cancer-Associated Stroke and Acute Endovascular Reperfusion Therapy

Since stroke is often associated with cancer, acute stroke patients with cancer undergoing endovascular therapy (EVT) are not uncommon. Reportedly, the proportion of such cases is approximately 6%-7% of all stroke EVT cases. Ischemic stroke in patients with active cancer (cancer-associated stroke) includes not only strokes caused by cancer-related hypercoagulability but also coincident strokes due to common etiologies, strokes associated with tumor emboli, direct tumor invasion of blood vessels, and strokes associated with cancer therapy. Stroke caused by cancer-related hypercoagulability itself encompasses various entities, including paradoxical embolism, stroke due to nonbacterial thrombotic endocarditis, and in situ arterial occlusion due to disseminated intravascular coagulation or thrombotic microangiopathy. Thus, diverse mechanisms contribute to cancer-associated stroke, emphasizing the need to consider individualized treatment strategies for acute cases involving large vessel occlusion. Observational studies have shown that EVT for cancer-associated stroke results in poorer clinical outcomes, but with comparable rates of successful reperfusion and symptomatic intracranial hemorrhage when compared with stroke patients without cancer. This suggests that denying patients EVT solely on the basis of comorbid active cancer is inappropriate, and decision-making should be shared with the patients and their families, preferably through a multidisciplinary team approach. Thrombi retrieved from patients with stroke caused by cancer-related hypercoagulability have unique characteristics, being predominantly platelet rich and difficult to retrieve. Preprocedural imaging and serum biomarkers, including the hyperdense vessel sign on non-contrast CT, susceptibility vessel sign on T2* or susceptibility-weighted MRI, three-territory sign on MRI, and D-dimer levels, are valuable in evaluating the stroke subtype and thrombus features. Thrombectomy techniques, such as contact aspiration and stent retriever monotherapy, have shown varying degrees of effectiveness for stroke caused by cancer-related hypercoagulability, warranting further study. After reperfusion therapy, appropriate treatment for the prevention of stroke recurrence should be initiated, considering the specific stroke subtypes. In conclusion, cancer-associated stroke encompasses diverse subtypes, and thrombi associated with stroke caused by cancer-related hypercoagulability present various challenges for thrombectomy. Individualized treatment approaches based on underlying mechanisms are essential for improving outcomes in acute stroke patients with active cancer. Optimization of preprocedural diagnosis, EVT techniques, and secondary prevention of stroke caused by cancer-related hypercoagulability will lead to better management of these patients and enhance their quality of life.

Endovascular therapy for acute ischemic stroke in patients with active malignancy: a meta-analysis with trial sequential analysis

BACKGROUND

Active malignancy has a poorer prognosis and more deaths in patients with acute ischemic stroke (AIS). The outcomes of endovascular therapy (EVT) remain controversial in patients with AIS and active malignancy.

METHODS

We searched PubMed, Cochrane, and Embase for articles published up to June 1, 2022. The primary outcome was good functional outcome at 3 months and successful reperfusion between patients with cancer and AIS and control patients. The secondary and safety outcomes included mortality at 3 months, in-hospital mortality, symptomatic intracerebral hemorrhage (sICH), any ICH, and subarachnoid hemorrhage (SAH).

RESULTS

Twelve studies involving 5944 patients with AIS secondary to EVT were included (389 patients having active malignancy). The OR of good functional outcome at 3 months was 0.53 (95% CI 0.41 to 0.67) between the two groups. The OR of successful reperfusion between the two groups was 0.90 (95% CI 0.63 to 1.30). Compared with patients without cancers, those with cancers had a higher risk of mortality at 3 months (OR 3.64; 95% CI 2.35 to 6.27) and in-hospital mortality (OR 3.46; 95% CI 1.71 to 7.01). Despite a higher point estimate regarding any ICH (OR 1.41; 95% CI 1.01 to 1.96) and SAH (OR 2.53; 95% CI 1.10 to 5.81), sICH (OR 0.85; 95% CI 0.51 to 1.42) was not significant.

CONCLUSION

Although a quarter of patients with active malignancy and AIS regained functional independence, physicians and patients should consider whether to apply EVT in patients with active malignancy.

Effects of tumor type on outcomes in patients with large vessel occlusion stroke and cancer

BACKGROUND

Large vessel occlusions (LVO) stroke is associated with cancer. Whether this association differs among patients with LVO that undergo endovascular thrombectomy (EVT) according to cancer type remains unknown.

PATIENTS AND METHODS

Data from consecutive patients that underwent EVT for LVO at three academic centers were pulled and analyzed retrospectively. Patients with LVO and solid tumors were compared to those with hematological tumors. Associations of cancer type with 90-day functional outcome and mortality were calculated in multivariable analyses.

RESULTS

Of the 154 patients with cancer and LVO that underwent EVT (mean age 74±11, 43% men, median NIHSS 15), 137 had solid tumors (89%) and 17 (11%) had hematologic tumors. Patients with solid cancer did not significantly differ from those with hematological malignancy in demographics, risk factor profile, stroke severity and subtype, and procedural variables. Outcome parameters including rates of favorable target recanalization and favorable outcome or mortality at discharge and 90 days post stroke were similar. Safety parameters including rates of symptomatic intracranial hemorrhage also did not differ between the groups. On regression analyses, controlling for various prognostic variables cancer type was not associated with mortality or favorable outcomes.

CONCLUSIONS

Our study suggests that the safety and efficacy of EVT in patients with malignancy does not depend on cancer type. Patients with malignancy should be considered for EVT regardless of cancer type.

Does Malignancy Status Effect Outcomes in Patients With Large Vessel Occlusion Stroke and Cancer Who Underwent Endovascular Thrombectomy?

Background Cancer is associated with an increased risk of acute ischemic stroke, including large vessel occlusions. Whether cancer status affects outcomes in patients with large vessel occlusions that undergo endovascular thrombectomy remains unknown. Methods and Results All consecutive patients undergoing endovascular thrombectomy for large vessel occlusions were recruited into a prospective ongoing multicenter database, and the data were retrospectively analyzed. Patients with active cancer were compared with patients with cancer in remission. Association of cancer status with 90-day functional outcome and mortality were calculated in multivariable analyses. We identified 154 patients with cancer and large vessel occlusions that underwent endovascular thrombectomy (mean age, 74±11; 43% men; median National Institutes of Health Stroke Scale 15). Of the included patients, 70 (46%) had a remote history of cancer or cancer in remission, and 84 (54%) had active disease. Outcome data at 90 days poststroke were available for 138 patients (90%) and was classified as favorable in 53 (38%). Patients with active cancer were younger and more often smoked but did not significantly differ from those without malignancy in other risk factors, stroke severity, stroke subtype, or procedural variables. Favorable outcome rates among patients with active cancer did not significantly differ compared with those seen in patients without active cancer, but mortality rates were significantly higher among patients with active cancer on univariate and multivariable analyses. Conclusions Our study suggests that endovascular thrombectomy is safe and efficacious in patients with history of malignancy as well as in those with active cancer at the time of stroke onset, although mortality rates are higher among patients with active cancer.

Mechanical Thrombectomy for Acute Ischemic Stroke in Patients with Malignancy: A Systematic Review

Background: Ischemic stroke is a common occurrence in patients with concomitant malignancy. Systemic thrombolysis is often contraindicated in these patients, and mechanical thrombectomy (MT) is the preferred method of intervention. This review aims to collect the available data on the safety and efficacy of MT in cancer patients (CPs).Methods: The PubMed/MEDLINE and SCOPUS databases were systematically searched for studies assessing safety (mortality, intracranial hemorrhage) and efficacy (reperfusion, functional outcome) indices in CPs receiving MT. Potentially relevant parameters examined in solitary studies were also extracted (e.g., stroke recurrence, brain malignancy).Results: A total of 18 retrospective studies of various methodologies and objectives were identified. Rates of in-hospital mortality, intracranial hemorrhage of any kind, reperfusion rates, and discharge condition did not seem to present any considerable differences between CPs and patients without cancer. On the contrary, 90-day mortality was higher and 90-day functional independence was lower in CPs. Three studies on cancer-related stroke (no other identifiable etiology and high D-dimer levels in the presence of active cancer) showed constant tendencies towards unfavorable conditions. Conclusions: Per the available evidence, MT appears to be a safe treatment option for CPs. It is still unclear whether the 90-day mortality and outcome rates are more heavily influenced by the malignancy and not the intervention itself, so MT can be considered in CPs with prospects of a good functional recovery, undertaking an individualized approach.