Abstract
Stroke in cancer patients is not infrequently encountered. Although both hemorrhagic and ischemic stroke can occur with cancer-associated coagulopathy, not all strokes in cancer patients can be attributed to cancer. In 1965, a French physician Armand Trousseau reported three patients presenting with migratory phlebitis who were later diagnosed as having cancer. Thus, the Trousseau syndrome does not necessarily refer to cerebral infarction. In fact, venous thromboembolism (deep venous thrombosis and pulmonary embolism) is the most frequent complication of cancer-related coagulopathy. As for stroke, nonbacterial thrombotic endocarditis (NBTE) is the most common type of stroke in cancer patients. Tiny sterile fibrin-platelet thrombi attached to the cardiac valves without destruction cause multiple cerebral infarctions in different arterial territories. The exact mechanism of NBTE in cancer patients remains to be established and intravenous thrombolysis with alteplase is not contraindicated. However, unexpected and devastating cerebral hemorrhage can occur after thrombolysis. Although unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or synthetic Xa inhibitors can be used to prevent the recurrence of stroke, long-term usage is often difficult because of disseminated intravascular coagulation (DIC) and exacerbation of the cancer status. Warfarin has been thought to be less effective, and non-vitamin K antagonist oral anticoagulants (NOACs) could be an alternative choice, but cogent evidence remains to be established at present.
