Recanalization therapy in stroke patients with malignancies: in-hospital outcomes by cancer subtype in a nationwide administrative data analysis

OBJECTIVE: Stroke is a common risk among patients with cancer, and the odds of a fatal stroke are estimated to be twice those of the general population. Due to the exclusion of cancer patients from major intravenous thrombolysis and thrombectomy trials, existing literature consists largely of small case series lacking sufficient statistical power. We aimed to evaluate the safety profile of acute stroke therapies in patients with active cancer, stratified by cancer localization, using a nationwide administrative dataset. METHODS: This retrospective, large-scale cohort study utilized data from the German Federal Statistical Office (DESTATIS). We analyzed all inpatient cases of acute ischemic stroke receiving recanalization therapy (intravenous thrombolysis and endovascular thrombectomy) in Germany. The primary endpoints were in-hospital mortality and safety outcomes (intracranial bleeding, subarachnoid hemorrhage, and acute anemia). To control for baseline characteristics, adjusted odds ratios (aOR) were calculated using multivariable logistic regression. RESULTS: We analyzed 154,333 patients receiving intravenous thrombolysis (2482 with and 151,851 without cancer) and 39,534 receiving endovascular thrombectomy (1580 with and 37,954 without cancer). In the thrombolysis cohort, patients with cancer had significantly higher rates of in-hospital death (10.88% vs. 6.26%; OR 1.83; p < 0.001) and intracranial bleeding (5.76% vs. 4.58%; OR 1.27; p = 0.005). Similarly, in the thrombectomy cohort, active cancer was associated with increased in-hospital mortality (28.10% vs. 20.00%; OR 1.56; p < 0.001) and subarachnoid hemorrhage (6.14% vs. 4.67%; OR 1.33; p = 0.007). After multivariable adjustment, stratification revealed highly heterogeneous complication profiles depending heavily on the specific cancer subtype. CONCLUSIONS: This large-scale analysis demonstrates that while mortality and specific bleeding risks are generally elevated in stroke patients with malignancies, these risks depend strongly on the cancer subtype. These findings advocate for a tailored, risk-based approach to recanalization therapy, weighing individual complication profiles rather than a general exclusion of patients with cancer from acute stroke therapies.