Endovascular therapy for acute ischemic stroke in patients with active malignancy: a meta-analysis with trial sequential analysis

Jhou, Hong-Jie; Yang, Li‐Yu; Chen, Po-Huang; Lee, Chien-Hsing

doi:10.1136/jnis-2022-019489

Cited by 3 publications

(3 citation statements)

References 41 publications

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“…AIS is also more likely to occur in cancer patients [ 21 ]. Patients with active malignancies have poorer functional outcomes and higher mortality rates than patients without active malignancies, even after reperfusion therapy [ 22 ]. Our study also found a significantly lower white blood count in the thrombocytopenia group, which could be explained by the white blood count platelet complex hypothesis [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

Is Thrombocytopenia an In-Hospital Mortality Risk Factor among Patients with Acute Ischemic Stroke? A Propensity Score-Matched Analysis from the MIMIC-IV Database

Wang

Yang

Lee

et al. 2023

JCM

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(1) Background: We aimed to evaluate the aspect of thrombocytopenia in patients with acute ischemic stroke (AIS); (2) Methods: Patients with AIS were recruited in the Medical Information Mart for Intensive Care IV database from 2008 to 2019. The thrombocytopenia was defined as a platelet blood count of less than 150 K/µL. We compared the patient characteristics and clinical outcomes using propensity score matching (PSM); (3) Results: Thrombocytopenia affected 151 out of the 1236 patients (12.2%). Patients with thrombocytopenia were older (70.5 ± 12.8 vs. 68.4 ± 14.4; SMD = 0.154) and had a higher Charlson comorbidity index (7.3 ± 2.5 vs. 6.7 ± 2.7; SMD = 0.228) and acute physiology score III (44.8 ± 21.0 vs. 38.2 ± 19.1; SMD = 0.328) than those without thrombocytopenia. The risk of in-hospital mortality did not increase linearly or nonlinearly with a lower platelet count (overall p value = 0.794; nonlinear p value = 0.646). After PSM, 147 pairs remained. Thrombocytopenia was not linked with in-hospital mortality (HR: 1.06, 95% CIs: 0.60–1.88); (4) Conclusions: We described the clinical characteristics of patients admitted for thrombocytopenia and AIS who did not receive reperfusion therapy; additionally, we found that thrombocytopenia was not an independent short-term risk factor of in-hospital mortality.

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Section: Discussionmentioning

confidence: 99%

Is Thrombocytopenia an In-Hospital Mortality Risk Factor among Patients with Acute Ischemic Stroke? A Propensity Score-Matched Analysis from the MIMIC-IV Database

Wang

Yang

Lee

et al. 2023

JCM

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“…Since it is well known that the coexistence of cancer and stroke is often observed, acute stroke patients with cancer undergoing EVT are not uncommon, as seen by the fact that approximately 6%-7% of all stroke EVT cases reportedly have cancer. [6][7][8] This review outlines the mechanisms of ischemic stroke in patients with cancer (in this review, ischemic stroke occurring in patients with active cancer are referred to as cancer-associated stroke); the efficacy of EVT; treatment strategies, including preprocedural evaluation; and prevention of recurrence after reperfusion therapy.…”

Section: Introductionmentioning

confidence: 99%

Cancer-Associated Stroke and Acute Endovascular Reperfusion Therapy

Hayakawa

2023

JNET

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Since stroke is often associated with cancer, acute stroke patients with cancer undergoing endovascular therapy (EVT) are not uncommon. Reportedly, the proportion of such cases is approximately 6%-7% of all stroke EVT cases. Ischemic stroke in patients with active cancer (cancer-associated stroke) includes not only strokes caused by cancer-related hypercoagulability but also coincident strokes due to common etiologies, strokes associated with tumor emboli, direct tumor invasion of blood vessels, and strokes associated with cancer therapy. Stroke caused by cancer-related hypercoagulability itself encompasses various entities, including paradoxical embolism, stroke due to nonbacterial thrombotic endocarditis, and in situ arterial occlusion due to disseminated intravascular coagulation or thrombotic microangiopathy. Thus, diverse mechanisms contribute to cancer-associated stroke, emphasizing the need to consider individualized treatment strategies for acute cases involving large vessel occlusion. Observational studies have shown that EVT for cancer-associated stroke results in poorer clinical outcomes, but with comparable rates of successful reperfusion and symptomatic intracranial hemorrhage when compared with stroke patients without cancer. This suggests that denying patients EVT solely on the basis of comorbid active cancer is inappropriate, and decision-making should be shared with the patients and their families, preferably through a multidisciplinary team approach. Thrombi retrieved from patients with stroke caused by cancer-related hypercoagulability have unique characteristics, being predominantly platelet rich and difficult to retrieve. Preprocedural imaging and serum biomarkers, including the hyperdense vessel sign on non-contrast CT, susceptibility vessel sign on T2* or susceptibility-weighted MRI, three-territory sign on MRI, and D-dimer levels, are valuable in evaluating the stroke subtype and thrombus features. Thrombectomy techniques, such as contact aspiration and stent retriever monotherapy, have shown varying degrees of effectiveness for stroke caused by cancer-related hypercoagulability, warranting further study. After reperfusion therapy, appropriate treatment for the prevention of stroke recurrence should be initiated, considering the specific stroke subtypes. In conclusion, cancerassociated stroke encompasses diverse subtypes, and thrombi associated with stroke caused by cancer-related hypercoagulability present various challenges for thrombectomy. Individualized treatment approaches based on underlying mechanisms are essential for improving outcomes in acute stroke patients with active cancer. Optimization of preprocedural diagnosis, EVT techniques, and secondary prevention of stroke caused by cancer-related hypercoagulability will lead to better management of these patients and enhance their quality of life.

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“…1–7 Two study-level meta-analyses did not show significant differences in 3-month disability, rates of symptomatic intracranial hemorrhage (sICH), or mortality between iPCAO patients treated with EVT and those with MM. 8,9 The largest patient-level analysis, involving 1023 iPCAO patients from the endovascular therapy of PLATO (Posterior Cerebral Artery Occlusion Stroke) collaboration, found that patients treated with EVT and MM had similar 3-month disability, without any significant difference on the distribution of the modified Rankin Scale (mRS). However, a higher proportion of patients treated with EVT had early neurological improvement and achieved excellent 3-month outcome (mRS score 0–1), yet with higher rates of sICH.…”

mentioning

confidence: 99%

Endovascular Versus Medical Therapy in Posterior Cerebral Artery Stroke: Role of Baseline NIHSS Score and Occlusion Site

Strambo,

Michel,

Nguyen

et al. 2024

Stroke

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Background: Acute ischemic stroke (AIS) with isolated posterior cerebral artery occlusion (iPCAO) lacks management evidence from randomized trials. We aimed to evaluate whether the association between endovascular treatment (EVT) and outcomes in iPCAO-AIS is modified by initial stroke severity (baseline NIHSS) and arterial occlusion site. Methods: Based on the multicenter, retrospective, case-control study of consecutive iPCAO-AIS patients (PLATO study), we assessed the heterogeneity of EVT outcomes compared to medical management (MM) for iPCAO, according to baseline NIHSS (≤6 vs. >6) and occlusion site (P1 vs. P2), using multivariable regression modelling with interaction terms. The primary outcome was the favorable shift of 3-month mRS. Secondary outcomes included excellent outcome (mRS 0-1), functional independence (mRS 0-2), symptomatic intracranial hemorrhage (sICH) and mortality. Results: From 1344 patients assessed for eligibility, 1,059 were included (median age 74 years, 43.7% women, 41.3% had intravenous thrombolysis), 364 receiving EVT and 695 MM. Baseline stroke severity did not modify the association of EVT with 3-month mRS distribution (pint=0.312), but did with functional independence (pint=0.010), with a similar trend on excellent outcome (pint=0.069). EVT was associated with more favorable outcomes than MM in patients with baseline NIHSS>6 (mRS 0-1: 30.6% vs. 17.7%, aOR=2.01, 95%CI=1.22-3.31; mRS 0-2: 46.1% vs. 31.9%, aOR=1.64, 95%CI=1.08-2.51), but not in those with NIHSS≤6 (mRS 0-1: 43.8% vs. 46.3%, aOR=0.90, 95%CI=0.49-1.64; mRS 0-2: 65.3% vs. 74.3%, aOR=0.55, 95%CI=0.30-1.0). EVT was associated with more sICH regardless of baseline NIHSS (pint=0.467), while the mortality increase was more pronounced in patients with NIHSS≤6 (pint=0.044, NIHSS≤6: aOR=7.95,95%CI=3.11-20.28, NIHSS>6: aOR=1.98,95%CI=1.08-3.65). Arterial occlusion site did not modify the association of EVT with outcomes compared to MM. Conclusion: Baseline clinical stroke severity, rather than the occlusion site, may be an important modifier of the association between EVT and outcomes in iPCAO. Only severely affected patients with iPCAO (NIHSS>6) had more favorable disability outcomes with EVT than MM, despite increased mortality and sICH.

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Endovascular therapy for acute ischemic stroke in patients with active malignancy: a meta-analysis with trial sequential analysis

Cited by 3 publications

References 41 publications

Is Thrombocytopenia an In-Hospital Mortality Risk Factor among Patients with Acute Ischemic Stroke? A Propensity Score-Matched Analysis from the MIMIC-IV Database

Is Thrombocytopenia an In-Hospital Mortality Risk Factor among Patients with Acute Ischemic Stroke? A Propensity Score-Matched Analysis from the MIMIC-IV Database

Cancer-Associated Stroke and Acute Endovascular Reperfusion Therapy

Endovascular Versus Medical Therapy in Posterior Cerebral Artery Stroke: Role of Baseline NIHSS Score and Occlusion Site

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