• cancer patients are at increased risk of not only venous (VTE) but also arterial thromboembolism (ATE),  including stroke and myocardial infarction (MI)  [Mulder, 2021] [Babak, 2015]
    • stroke is not the most common complication of cancerassociated thrombosis; the hazard ratio (HR) for stroke is ~ 1.44   [Paterson, 2022]
    • the highest risk of stroke is associated with pancreatic, breast, lung, and colorectal tumors
    • most patients with cancer and stroke are elderly males
  • some strokes are directly related to the tumor or metastases, while others are linked to diagnostic methods or therapy (</span><span style=”font-size: 14px;”>early and delayed cardiovascular complications)
  • in cryptogenic stroke,a cancer survey is suggested as thromboembolism may be the first manifestation of the disease
    • significantly increased D-dimers have been found in patients with cryptogenic stroke and occult cancer (Schwarzbach, 2012)


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
      • this condition results from damage to blood vessels due to chemotherapy drugs (such as bevacizumab, cisplatin, 5-Fluorouracil, etc.), potentially leading to endothelial damage, vascular inflammation, and blood clot formation
Primary Secondary
  • CNS and cranial nerves
    • encephalomyelitis
    • subacute cerebellar degeneration
    • opsoclonus/myoclonus syndrome
    • limbic encephalitis
    • optic neuritis
    • tumor-associated retinopathy
    • necrotizing myelopathy
    • motor neuron disease
    • stiff person syndrome
    • peripheral nerve lesions
    • polyneuropathy
    • polyradiculoneuritis
  • neuromuscular transmission disorders
    • Lambert-Eaton
    • myasthenia gravis
  • muscle disorders
    • myotonia
    • myopathy (cachectic, carcinoid)
  • vasculitis
  • hematological disorders
    • thrombocytopenia, thrombocytosis
    • coagulation disorders
    • acquired von Willebrand’s disease (disorder in which the blood does not clot properly)   (Jin, 2014)
  • nonbacterial noncarditis
  • hyperviscosity syndrome
  • metabolic disorders
  • infections
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  • hypercoagulable state
  • autoimmune disorders
    • paraneoplastic vasculitis
    • antiphospholipid syndrome (APL)
    • acquired von Willebrand syndrome
    • microangiopathic hemolytic anemia
  • nonbacterial (marantic) endocarditis with emboli
  • angiopathy
    • radiation-induced vasculopathy
    • compression of a blood vessel by a tumor
    • tumor invasion into the vessel with its occlusion or embolization of tumor masses peripherally
    • neoplastic vasculitis
  • an adverse effect of chemotherapy
    • microangiopathy
    • cardiac toxicity

Clinical presentation

  • similar proportions of ischemic stroke and bleeding are observed, while cerebral sinus thrombosis occurs less frequently
    • hemorrhage is more common in leukemias
    • ischemic stroke is more frequently seen 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 associated with paraneoplastic syndrome (limbic encephalitis, etc.) and therapy-induced encephalopathies

Diagnostic evaluation

  • standard imaging methods (CT+CTA / MR+MRA, neurosonology)
    • often multiple lesions (even in hemorrhages)
    • in DDx distinguish tumorous infiltration from ischemia  Histologically confirmed multiple metastases of lung adenocarcinoma  Histologically proven malignant non-Hodgkin's lymphoma 
  • blood tests
    • complete blood count (CBC) + coagulation tests + erythrocyte sedimentation rate (ESR)
    • basic metabolic panel
    • in suspected vasculitis, perform cerebrospinal fluid (CSF) examination
  • look for other vascular manifestations of the tumor (venous thrombosis in legs, venous thrombosis in atypical localisations, migrating thrombophlebitis, etc.)


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 cancerassociated 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

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Cancer-related stroke
link: https://www.stroke-manual.com/cancer-related-stroke/