ISCHEMIC STROKE / CLASSIFICATION AND ETIOPATHOGENESIS
Cancer-related stroke
- cancer patients are at increased risk of not only venous but also arterial thromboembolism (ATE), including stroke and MI) [Mulder, 2021] [Babak, 2015]
- stroke is, however, not the most common complication of cancer–associated thrombosis; HR for stroke is approx. 1.44 [Paterson, 2022]
- the highest risk of stroke is with pancreatic, lung, and colorectal tumors
- stroke is, however, not the most common complication of cancer–associated thrombosis; HR for stroke is approx. 1.44 [Paterson, 2022]
- some strokes are directly related to the tumor or metastases, others to diagnostic methods or therapy (early and delayed cardiovascular complications)
- in cryptogenic stroke, cancer survey is suggested ⇒ thromboembolism may be the first manifestation of the disease
- tremendously increased D-dimers have been found in patients with cryptogenic stroke and occult cancer
Etiopathogenesis
The cause of a cancer-related stroke is usually complex; multiple mechanisms may contribute:
- secondary paraneoplastic syndromes
- nonbacterial endocarditis and hypercoagulable state are common causes
- vasculitides are rare – only ~5% of vasculitides are paraneoplastic in origin, and only a small percentage of these lead to ischemia [Sánches-Guerrero, 1990]
- early or delayed complications of therapy (Anand, 2016)
- cardiomyopathies (anthracyclines or trastuzumab)
- systemic hypertension
- myocardial ischemia
- pulmonary hypertension
- radiation-induced vasculopathy
- chemotherapy-induced vasculopathy
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Clinical presentation
- similar proportions of ischemic stroke and bleeding, cerebral sinus thrombosis occurs less frequently
- hemorrhages are frequent in leukemias
- ischemic strokes typically occur in carcinomas and lymphomas
- focal neurological deficit corresponds to the affected vascular territory
- frequent signs of progressive encephalopathy, caused by:
- multiple embolizations in marantic endocarditis
- hypercoagulable state with multiple infarcts
- vasculitis
- differentiate encephalopathy related to paraneoplastic syndrome (limbic encephalitis, etc.) or therapy-induced encephalopathies
Diagnostic evaluation
- standard imaging methods (CT+CTA / MR+MRA, neurosonology)
- blood tests
- complete blood count (CBC) + coagulation tests + erythrocyte sedimentation rate (ESR)
- basic metabolic panel
- in suspected vasculitis, perform CSF examination
- complete blood count (CBC) + coagulation tests + erythrocyte sedimentation rate (ESR)
- look for other vascular manifestations of the tumor (venous thrombosis in legs, venous thrombosis in atypical localisations, migrating thrombophlebitis, etc.)
Management
Acute stroke therapy
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- individual assessment of bleeding risk and the potential benefit is necessary; take into account the patient’s prognosis
- avoid IV thrombolysis in patients with:
- ↑ risk of bleeding
- an infaust prognosis with an expected survival of < 6 months
Conservative therapy and stroke prevention
- cancer treatment + symptomatic treatment of hematological disorders
- for non-cardioembolic stroke, prescribe aspirin 100 mg/d
- the application of anticoagulants in stroke patients with cancer–associated hypercoagulability is controversial; some authors suggest LMWH or DOACs (Hsu, 2019)
- the application of anticoagulants in stroke patients with cancer–associated hypercoagulability is controversial; some authors suggest LMWH or DOACs (Hsu, 2019)
- in atrial fibrillation or concurrent DVT, prefer DOACs or LMWH to warfarin (AHA/ASA 2021 2a/B-R)
- in cancer-related thrombosis and thromboembolism, avoid warfarin