Recurrent Thromboembolic Events after Ischemic Stroke in Patients with Primary Brain Tumors

Abstract

Background Stroke mechanisms and the risk of recurrent thromboembolism are incompletely understood in patients with primary brain tumors. We sought to better delineate these important clinical features. Methods We performed a retrospective cohort study of adults with primary brain tumors diagnosed with MRI-confirmed acute ischemic stroke at Memorial Sloan Kettering Cancer Center from 2005 to 2015. Study neurologists collected data on patients’ cancer history, stroke risk factors, treatments, and outcomes. Stroke mechanisms were adjudicated by consensus. The primary outcome was recurrent thromboembolism (arterial or venous) and the secondary outcome was recurrent ischemic stroke. Kaplan-Meier statistics were used to calculate cumulative outcome rates, and Cox hazards analysis was used to evaluate the association between potential risk factors and outcomes. Results We identified 83 patients with primary brain tumors and symptomatic acute ischemic stroke. Median survival after index stroke was 2.2 years (interquartile range, 0.5–7.0). Tumors were mostly gliomas (72%) and meningiomas (13%). Most strokes were from unconventional mechanisms, particularly radiation vasculopathy (36%) and surgical manipulation (18%). Small-or large-vessel disease or cardioembolism caused 13% of strokes, while 29% were cryptogenic. Cumulative recurrent thromboembolism rates were 11% at 30 days, 17% at 180 days, and 27% at 365 days; while cumulative recurrent stroke rates were 5% at 30 days, 11% at 180 days, and 13% at 365 days. We found no significant predictors of outcomes. Conclusions Patients with primary brain tumors generally develop strokes from rare mechanisms and their risk of recurrent thromboembolism, including stroke, is high.

Ischemic stroke in cancer patients: A review of an underappreciated pathology

“…47,49 Most strokes from radiation vasculopathy develop many years after treatment. 52 A caveat is that increased stroke risk in cancer patients could be due to confounding bias from risk factors associated with both cancer and stroke, especially smoking. However, this is unlikely to fully explain the association between cancer and stroke, because several cancers not tied to smoking, such as non-Hodgkin lymphoma, have been associated with increased stroke risk.…”

“…Intracranial artery compression and invasion are another rare cause of stroke with cancer, typically occurring in patients with glioblastoma multiforme. 52 Hyperviscosity occasionally causes stroke in patients with hematological malignancies. Besides arterial causes, cerebral vein thromboses should also be evaluated for in cancer patients with stroke.…”

Cancer-Related Stroke: An Emerging Subtype of Ischemic Stroke with Unique Pathomechanisms

“…20 In addition, treatment of cancer can increase the risk of stroke, e.g., accelerated atherosclerosis after radiation therapy. 21,22 Rarely, occlusion of brain vessels by tumor cells (tumor embolism) occurs in patients with solid tumors of the lung or heart (e.g., cardiac myxoma) that access arterial circulation by invading pulmonary veins or cardiac chambers, and in patients with intravascular lymphoma, a subset of diffuse large B-cell lymphoma. 23,24 Stroke due to cancer-related coagulopathy is a definable disease entity, as unique characteristics of this condition were reported among studies from different populations.…”

Thrombotic Complications in Gliomas

“…95 Radiation-induced vasculopathy is a well-known consequence of radiotherapy and increases the risk of stroke. 97,98 The majority of strokes occur years after treatment, and the incidence of stroke increases with time. [98][99][100][101] Radiation vasculopathy can affect both large and small vessels.…”

“…97,98 The majority of strokes occur years after treatment, and the incidence of stroke increases with time. [98][99][100][101] Radiation vasculopathy can affect both large and small vessels. The underlying pathophysiology of radiation vasculopathy involves accelerated atherosclerosis and injury to the vasa vasorum.…”