Factors related to white thrombi in acute ischemic stroke in cancer patients

Abstract

Objectives Thrombi in cerebral large vessel occlusion associated with active cancer are often fibrin and platelet-rich white thrombi. However, evaluating the thrombus composition in a short time before thrombectomy is often ineffective. We sought to determine factors related to white thrombi in acute ischemic stroke due to large vessel occlusion in cancer patients. Methods Consecutive cancer patients undergoing thrombectomy for acute ischemic stroke due to large vessel occlusion between January 2018 and May 2022 were retrospectively reviewed. The patients were classified into white thrombus and red thrombus groups on the basis of the pathological findings of retrieved thrombi. Patient characteristics and laboratory findings were compared between the two groups. Results There were 12 patients in the white thrombus group and 11 patients in the red thrombus group. Active cancer was significantly more in the white thrombus group than in the red thrombus group (91.7% vs. 36.3%, p = 0.0094). Internal carotid artery occlusion was significantly less in the white thrombus group than in the red thrombus group (0% vs. 36.4%, p = 0.037). Among laboratory findings, D-dimer levels were an independent factor associated with white thrombi (odds ratio 8.97 [95% confidence interval 1.71–368.99], p < 0.0001). The cutoff value of D-dimer levels for predicting white thrombi was 3.5 μg/mL (83.3% sensitivity and 100% specificity). Conclusions In acute ischemic stroke in cancer patients, active cancer, no internal carotid artery occlusion, and higher D-dimer levels (≥3.5 μg/mL) may be associated with occlusion with fibrin and platelet-rich white thrombi.

Ischemic Stroke in Cancer: Mechanisms, Biomarkers, and Implications for Treatment

“…In another study, white clots in cancer patients were independently associated with increased D-dimer levels and worse prognosis compared to "red clots" (RBCs-rich thrombi). 99 Although based on small studies, these results indicate that platelet dysfunction plays an important role in cancer-related stroke.…”

“…97 Susceptibility-weighted imaging (SWI) imaging on MRI detects local distortion of the magnetic field induced by paramagnetic substances, such as red blood cells (RBCs) entrapped in thrombi in patients with large vessel occlusions (LVOs), resulting in a hypointense signal defined as the “susceptibility vessel sign” (SVS). 98 Since thrombi in cancer patients typically have lower RBC fractions, 99 the absence of SVS may be another biomarker of occult cancer. However, a recent study by Beyeler et al on 40 AIS patients with cancer found that the absence of SVS was associated with having a cancer but could not predict occult cancer better than clinical predictors.…”

Cancer-Associated Stroke: Thrombosis Mechanism, Diagnosis, Outcome, and Therapeutic Strategies

“…Thrombi in cancer-associated stroke are visibly white, allowing for suspicion of cancer as the underlying cause upon thrombus retrieval in the angiographic suite. 35,36 On hematoxylin and eosin-stained thrombi, a fibrin/platelet proportion of ≥65% accurately predicted cancer-associated stroke, with an area under the curve of 0.84. 33 Although platelets cannot often be accurately differentiated from fibrin on hematoxylin and eosin staining, substantial fractions of fibrin are present in the thrombi of conventional stroke etiologies.…”

“…Thrombus examination is crucial for diagnosing cancer-associated stroke. Thrombi in cancer-associated stroke are visibly white, allowing for suspicion of cancer as the underlying cause upon thrombus retrieval in the angiographic suite [ 35 , 36 ]. On hematoxylin and eosin-stained thrombi, a fibrin/platelet proportion of ≥65% accurately predicted cancer-associated stroke, with an area under the curve of 0.84 [ 33 ].…”

Preprocedural D-Dimer Level as a Predictor of First-Pass Recanalization and Functional Outcome in Endovascular Treatment of Acute Ischemic Stroke

“…Because plasma D-dimer reflects the activation of the coagulation pathway and corresponding hyperfibrinolysis, the conditions of thrombus formation might be altered by different 2 of 12 D-dimer levels. For example, in cancer-related stroke, which always accompanies a fairly high D-dimer level, platelet-rich or white thrombi are predominantly observed [11,12]. Presumably, plasma D-dimer levels might affect endovascular and further clinical outcomes through various thrombogenic conditions or types of thrombus.…”