Acidente vascular cerebral isquêmico após quimioterapia com cisplatina, etoposide e bleomicina: relato de caso

Abstract

1RESUMO -Relatamos o caso de um homem de 20 anos, com diagnóstico de tumor de células germinativas, que apresentou acidente vascular cerebral isquêmico durante quimioterapia com cisplatina, etoposide e bleomicina. Os casos relatados na literatura foram revisados, bem como os diferentes mecanismos fisiopatológicos implicados na toxicidade vascular deste esquema quimioterápico. PALAVRAS-CHAVES: cisplatina, bleomicina, etoposide, quimioterapia, toxicidade, acidente vascular cerebral.Ischemic stroke after chemotherapy with cisplatin, etoposide and bleomycin: case report Ischemic stroke after chemotherapy with cisplatin, etoposide and bleomycin: case report Ischemic stroke after chemotherapy with cisplatin, etoposide and bleomycin: case report Ischemic stroke after chemotherapy with cisplatin, etoposide and bleomycin: case report Ischemic stroke after chemotherapy with cisplatin, etoposide and bleomycin: case report ABSTRACT -A 20-year-old man with a germ cell tumor who experienced an ischemic stroke as a complication of cisplatin/etoposide/bleomycin based chemotherapy is reported. The previously reported cases are reviewed as well as the different physiopathologic mechanisms associated with vascular toxicity of this regimen.KEY WORDS: cisplatin, etoposide, bleomycin, chemotherapy, toxicity, stroke. Embora os pacientes com câncer sistêmico apresentem elevado risco de eventos tromboembólicos, estes fenômenos comprometem especialmente o sistema venoso, sendo relativamente incomum o comprometimento da circulação arterial 1 . Cerca de 90% dos pacientes com câncer podem apresentar alterações da coagulação, tais como aumento da agregação plaquetária, maior atividade de fatores pró-coagulantes como pró-trombinase e fator X, e, por outro lado, menor atividade dos fatores anticoagulantes 1 . Além destes fatores, também o risco de trombose arterial pode aumentar quando é administrada 1,2 a terapia antiblástica. Os esquemas quimioterápicos que incluem a cisplatina e bleomicina são amplamente utilizados no tratamento de tumores sólidos, especialmente nos tumores de células germinativas 1 . Os principais efeitos colaterais relacionados com estes esquemas são náuseas e vômitos, nefrotoxicidade, hipomagnesemia, neuropatia periférica, ototoxicidade e mielossupressão [3][4][5][6][7][8][9][10] . Há também relatos de toxicidade vascular manifesta clinicamente por insuficiência coronariana (desde angina até infarto miocárdico), fenômeno de Raynaud e de acidente vascular cerebral, demonstrando que, embora pouco descrita, a toxicidade vascular pode ser importante efeito colateral deste tratamento [10][11][12][13][14][15][16][17][18][19] . Relatamos o caso de um paciente que apresentou acidente vascular cerebral isquêmico em vigên-cia de esquema quimioterápico com cisplatina, bleomicina e etoposide e revisamos os mecanismos da toxicidade deste esquema quimioterápico.

Extensive arterial and venous thrombo-embolism with chemotherapy for testicular cancer: a case report

“…Increase in Von-willebrand factor antigen, endothelial dysfunction, alterations of clotting cascade, thromboxane-prostacyclin homeostatic disturbances, and stimulation of fibroblasts [1,7-9] add to the propensity of thrombotic events with cisplatin. Cisplatin is also known to cause autonomic dysfunction [10] and hypomagnesemia, both of which could potentiate the arterial spasm, as magnesium seems to have an important role in maintaining the tone of the muscular layer of vessels [11]. …”

Unusually Located Stroke After Chemotherapy in Testicular Germ Cell Tumors

“… 26 Another case report by Karagoz et al presented a 34-year-old patient who developed aphasia and hemiplegia 10 days after the third CHT cycle, 29 and the report of Santos et al, whose 20-year-old patient developed hemiparesis and hemihypoesthesia 14 days after the second CHT cycle. 3 Azak et al described the case of a 17-year-old patient who presented an IS 7 days after the fourth CHT cycle. With this case, in particular, the ischemic events were hemorrhagic infarctions.…”

“…Up to 90% of cancer patients suffer hemostatic alterations, represented by an increased platelet aggregation, increased activity of procoagulant factors, decreased activity of anticoagulant factors, and increased levels of fibrinogen, which induce a state of hypercoagulability, 3 - 6 increasing the risk of ischemic stroke (IS). Nonetheless, there are other influencing mechanisms, such as tumor vascular compression or infiltration and toxic side effects of radiotherapy or chemotherapy (CHT).…”

“…These last 2 drugs produce vascular toxicity as a collateral effect. 3 , 5 , 6 , 8 , 9 The TEEs can result in higher morbidity rates, impaired quality of life, and, in some cases, may put the patient’s life at risk. 5 …”

“…Many reports have been written about ischemic or hemorrhagic stroke that occurred several days after cisplatin infusion and which have possible etiological factors related with vascular injury, altered platelet aggregation, or increased plasma levels of von Willebrand factor antigen (vWF:Ag). 3 , 6 , 22 , 24 …”