ISCHEMIC STROKE / CLASSIFICATION AND ETIOPATHOGENESIS

• 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 cancer–associated 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

• 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
    

• standard imaging methods (CT+CTA / MR+MRA, neurosonology)
  • often multiple lesions (even in hemorrhages)
  • in DDx distinguish tumorous infiltration from ischemia    
• 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.)