Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke

Abstract

Objective:To explore clinical and safety outcomes of patients with acute ischemic stroke (AIS) and active cancer after endovascular treatment (EVT).Methods:Using data from the MR CLEAN Registry, we compared patients with active cancer (defined as cancer diagnosed within 12 months prior to stroke, metastatic disease, or current cancer treatment) to patients without cancer. Outcomes were 90-day modified Rankin Scale (mRS) score, mortality, successful reperfusion (eTICI scores≥2b), symptomatic intracranial hemorrhage (sICH), and recurrent stroke. Subgroup analyses were performed in patients with a pre-stroke mRS score of 0 or 1 and according to treatment setting (curative or palliative). Analyses were adjusted for prognostic variables.Results:Of 2583 patients who underwent EVT, 124 (4.8%) had active cancer. They more often had pre-stroke disability (mRS≥2: 34.1% vs. 16.6%). The treatment setting was palliative in 25.3% of the patients. There was a shift towards worse functional outcome at 90 days in patients with active cancer (adjusted common OR 2.2, 95% CI 1.5-3.2). At 90 days, patients with active cancer were less often independent (mRS 0-2: 22.6% vs. 42.0%, aOR 0.5, 95% CI 0.3-0.8), and more often dead (52.2% vs. 26.5%, aOR 3.2, 95% CI 2.1-4.9). Successful reperfusion (67.8% vs. 60.5%, aOR 1.4, 95% CI 1.0-2.1) and sICH rates (6.5% vs. 5.9%, aOR 1.1, 95 %CI 0.5-2.3) did not differ. Recurrent stroke within 90 days was more common in patients with active cancer (4.0% vs. 1.3%, aOR 3.1, 95% CI 1.2-8.1). The sensitivity analysis of patients with a pre-stroke mRS of 0 or 1 showed that patients with active cancer still had a worse outcome at 90 days (acOR 1.9, 95% CI 1.2-3.0). Patients with active cancer in a palliative treatment setting regained functional independence less often compared to patients in a curative setting (18.2% vs. 32.1%) and mortality was also higher (81.8% vs. 39.3%).Conclusions:Despite similar technical success, patients with active cancer had significantly worse outcomes after EVT for AIS. Moreover, they had an increased risk of recurrent stroke. Nevertheless, about a quarter of the patients regained functional independence and the risk of other complications, most notably sICH, was not increased.Classification of Evidence:This study provides Class I evidence that patients with active cancer undergoing EVT for AIS have worse functional outcomes at 90 days compared to those without active cancer.

Reader Response: Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy

“…We thank the authors for their contribution to an improved understanding of efficacy and complications of endovascular treatment (EVT) in patients with active malignancy. 1 The findings of the study that patients with active cancer experienced worse outcomes after EVT, even with favorable prestroke function and technical success, is in agreement with data from the ESCAPE and ESCAPE-NA1 trials of EVT. In both these trials, we found that experiencing comorbid cancer was strongly associated with poor functional outcomes according to the modified Rankin scale score in patients at 90 days, despite achieving small final infarct volumes after EVT.…”

Author Response: Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy

“…We thank Moores and Ganesh for their comments on our research 1 and for drawing our attention to their 2 studies. 2,3 Both these studies report on 4 patients with cancer, but do not state whether the cancer was active.…”

Mechanical Thrombectomy for Acute Ischemic Stroke in Patients with Malignancy: A Systematic Review

“…All of the included studies were retrospective analyses of either files/databases of patients that received acute treatment for AIS [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ], or analyses of hospital records with the use of diagnostic codes, e.g., ICD codes for AIS and malignancy [ 20 , 21 , 22 ]. One study was a retrospective analysis of cancer patients from the MR CLEAN thrombectomy study registry [ 23 ].…”