Ischemic stroke in patients with gliomas at The University of Texas-M.D. Anderson Cancer Center

Abstract

Patients with gliomas are at risk of cerebrovascular accidents (CVA) with potential consequences on survival, function, and local tumor control. Our objective was to provide information about CVA in patients with gliomas and to estimate survival in this group. We reviewed all adult glioma patients with ischemic CVA at the University of Texas-M.D. Anderson Cancer Center from 2003 through 2014. We extracted demographic, clinical, imaging, treatment and outcome data. We used descriptive summary data and estimated or compared survival rates where appropriate. 60 of 6500 patients (0.1%) with high-grade (HGG, n = 47) or low-grade glioma (LGG, n = 13) had ischemic CVA Thirty-two (53%) patients had postoperative strokes, and 20 (33%) had CVA after 2 weeks of surgery. Forty-one patients (68%) had gross total resection. For HGG and CVA, the poststroke median overall survival was 17 months versus 61 months in LGG and CVA (P = 0.03; hazard ratio (HR): 2.8; 95% CI 1.07-4.60). Survival stratified by modified Rankin Scale grade was significant (X(2) = 9.8, P = 0.007). Five patients received bevacizumab before stroke onset; none responded to antiangiogenic therapy. There was no stroke-related death. At our institution for 10 years, ischemic CVA in glioma patients was a rare complication, clearly associated in half of cases to surgery, and with a variable negative impact on performance status and neurologic function. In this group, patients with more neurological deficits lived less. The survival difference between and within subgroups was most likely due to tumor grade. More research is necessary to improve prevention of postoperative stroke in glioma patients.

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

“…These results are consistent with prior smaller studies that have also reported radiation vasculopathy and surgical injury to be common causes of stroke in the primary brain tumor population. (8, 10) However, the perioperative stroke rate in our cohort was less than in previous studies, perhaps because we included all primary brain tumor types (not just gliomas) and we excluded incidental strokes from our primary analysis. (8–10) We also found that patients with radiation vasculopathy had a non-significant trend towards a higher recurrent stroke rate.…”

“…(8, 10) However, the perioperative stroke rate in our cohort was less than in previous studies, perhaps because we included all primary brain tumor types (not just gliomas) and we excluded incidental strokes from our primary analysis. (8–10) We also found that patients with radiation vasculopathy had a non-significant trend towards a higher recurrent stroke rate. Prior research has shown that cervicocephalic radiation is a strong risk factor for cerebrovascular complications in children and adults.…”

“…(7) It is uncertain whether patients with primary brain tumors and ischemic stroke also face an increased risk of recurrent thromboembolism, as prior small studies have suggested that stroke in this population is more often from non-coagulopathic mechanisms such as radiation vasculopathy and surgery. (8–10) However, childhood cancer survivors with prior cranial radiation face an elevated stroke risk. (11–13) Additionally, some primary brain tumors have been associated with hypercoagulability.…”

Thrombotic Complications in Gliomas

“…76,77 While stroke can be the first clinical manifestation of malignancy, 78 the majority of ischemic strokes occur in the postoperative period. 79,80 The diagnosis can often be challenging both clinically and radiographically. 81 Acute onset of neurologic deficits can suggest a vascular event, but the differential can include underlying tumor progression and cerebral edema, as well as seizure.…”

“…In addition, asymptomatic strokes are also common and can be found in 15 to 22% of glioma patients. 77,80 Pathophysiology Atrial fibrillation, hypertension, hyperlipidemia, diabetes, and tobacco use remain common risk factors for ischemic stroke, irrespective of malignancy. However, conventional cerebrovascular risk factors can be absent in up to 40% of cancer patients.…”