Acute Stroke Thrombolysis in Cancer Patients: Where Do We Stand Now?

Sir, Cancer survivorship is increasing, and in the near future, over 60% of patients are expected to survive for five years or more after being diagnosed with cancer.[1] The prevalence of stroke in the setting of malignancy is 15% (a twofold additional risk over the traditional risk factors). Thus, we should be prepared to face more cancer patients with acute stroke. Currently, family members of cancer patients, particularly those recently diagnosed, often accompany them to an emergency room for an acute stroke, experiencing intense emotions and fear of their imminent demise. Stroke thrombolysis in this scenario is a very difficult decision to make as there remains a higher risk of hemorrhagic transformation, further stroke, and systemic embolism. Poststroke mortality in the general population is 15–20%, while in cancer patients it is up to 50%.[2] Adding to our woes, most of the acute ischemic stroke trials excluded malignancy, and we do not have a definite guideline regarding stroke thrombolysis in this group of patients. The existent guideline states: thrombolytic therapy for acute stroke in patients with cancer is not associated with increased risk of intracerebral hemorrhage or in-hospital mortality, but careful consideration of the cancer subtype is necessary. Though intracerebral hemorrhage post-thrombolysis did not differ among cancer subtypes, solid tumors without metastases (epithelial tumors, gastric, colon, prostate cancers, and sarcomas), intra-axial brain tumors, and metastatic cancer had lower home discharge and higher hospital mortality compared to liquid tumors (hematologic malignancies) following acute stroke intervention. Apart from the severity of stroke and metastasis, the predictors of mortality in cancer-associated stroke patients are the presence of hemorrhagic transformation of the infarct, the absence of a classical cause of stroke, the presence of diabetes, high CRP, and D-dimer levels. Though the outcome of endovascular therapy did not differ between cancer and non-cancer patients (as per the MR CLEAN EVT registry), the result of thrombolysis differs in the groups. So, assessment of the comorbidities (like utilizing the Elixhauser comorbidity index), using the other prognosticator markers post-thrombolysis, and taking into account predictors of hemorrhagic transformation (CCL-24, IL-6, IL-18) are necessary to select candidates for thrombolysis.[3] It is advisable to do a contrast-enhanced MRI of the brain to rule out minor hemorrhagic transformation and even small brain metastasis before performing thrombolysis (as it may influence the outcome significantly). Advanced imaging modalities, like the multilayer perceptron (MLP) model, may be utilized in the future for predicting a chance of symptomatic intracerebral hemorrhage after thrombolysis.[4] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.