Vertebral Artery Occlusion After Chemotherapy

Abstract

Vertebral Artery Occlusion After ChemotherapyTo the Editor:We have read the interesting report by Periard et al about cisplatin-induced strokes. 1 The role of tumors as risk factors for vascular disorders has long been established. However, there is little evidence regarding the effects of chemotherapy. Several reports describe vascular toxicity in young patients treated with cisplatin, and these studies suggest a casual link. 2,3 We present a patient who experienced a stroke due to vertebral artery occlusion after chemotherapy.A 48-year-old female patient was admitted to our hospital with nausea, vomiting, and headache. The patient also complained of tingling in the left side of her face. She had previous history of ovarian thecoma that was treated surgically on 3 occasions because of relapse and was finally treated with chemotherapy. The first dose of cisplatin, etoposide, and bleomycin was given 4 days before admission.On admission she presented with Horner syndrome, facial asymmetry, impaired elevation of the left soft palate and dysfonia. She also had dismetria in left arm. Her gait deviated to the left side.Blood tests were unremarkable, except for low leukocyte levels, with low neutrophyle level, which was related to the side effects of chemotherapy, as levels returned to normal in posterior tests without specific treatment. The MRI showed brain damage in the left occipital region, left cerebellum hemisphere, and left thalamus compatible with acute ischemic stroke in the vertebralbasilar territory. MRI angiography showed obstructed flow in the left vertebral artery with no other abnormalities. Thrombophiliaautoimmunity screening, syphilis, and HIV tests, ECG, echocardiogram, cerebral spinal fluid, and chest x-ray were unremarkable. The patient treated with clopidogrel recovered properly in the following days. Therefore, we report the case of a patient with an ischemic stroke just after the first course of chemotherapy. She did not have other risk factors for cerebrovascular disease. Vascular events have been described as a rare complication in relation to anticancer drugs. 4 Specifically, some authors have reported events in relation to cisplatin, [1][2][3][5][6][7] as well as to the combination of cisplatin, etoposide, and bleomycin. 2,5,6 We have not found any other case in literature of occlusion of a big cerebral artery induced by chemotherapy. Cases of aortic and other peripheral artery occlusion have been described. 3,4,6 As for brain arteries, only cases of carotid branch thrombosis have been found. 2,7 The case reported here would be the first one related to a vertebral artery.The mechanisms of such vascular events are probably multifactorial (endovascular damage, platelet aggregation, vasospasm or abnormalities in the coagulation cascade directly produced or induced by chemotherapy). [1][2][3][5][6][7] In agreement with all the referred authors, it is concluded that once a vascular event has occurred, discontinuation of cisplatinbased chemotherapy is mandatory.

Risk of ischemic stroke in patients with ovarian cancer: a nationwide population-based study

“…demonstrated that platinum in a chemotherapy regimen, which is also commonly used for treating ovarian cancer patients, may increase the risk of ischemic stroke among cancer patients [31]. Cerebral infarction after cisplatin-based chemotherapy in ovarian cancer patients has also been reported previously [32,33]. A meta-analysis of 38 randomized phase II and III trials showed that cancer patients who received cisplatin-based chemotherapy demonstrated a dose-dependently increased risk (RR 1.67, 95% CI, 1.25 to 2.23; P  = 0.01) of thromboembolism compared with patients who received a non-cisplatin-based regimen [34].…”

Acute Stroke Secondary to Carotid Artery Dissection in a Patient with Germ Cell Tumour: Did Cisplatin Play a Role?

“…Following a vascular event, the decision to continue or discontinue cisplatin-based chemotherapy should be individualised. Some authorities recommend discontinuation of cisplatin [6] and using alternative systemic treatment regimens or radiotherapy. Some patients may be advised to remain on cisplatin-based chemotherapy accompanied by anticoagulation, such as our patient.…”

“…[2,3,5]. The pathophysiologic basis of this vascular toxicity is not fully understood, and several mechanisms have been proposed: acute effects on vascular endothelium leading to endovascular damage and dysfunction, hypomagnesaemia, vasospasm, abnormalities in the coagulation cascade directly produced or induced by chemotherapy such as platelet aggregation or elevated plasma von Willebrand factor levels [6,7]. …”

Vascular Toxicities of Cancer Therapies

“…145 This may explain why in some cases no cause of ischemic stroke can be identified while in other cases local cranial artery thromboses can occur to the point of acute complete occlusions. 146 …”