IV Thrombolysis With or Without Endovascular Treatment for Suspected Ischemic Stroke in Patients With Intracranial Tumors

Katharina Seystahl; Nicolas Martinez-Majander; Alexander Salerno; Morin Beyeler; Hebun Erdur; João Pedro Marto; Christian Hametner; Marialuisa Zedde; Alessandro Pezzini; Ronen Leker; Valerian Altersberger; Gianluca Costamagna; Miguel Serôdio; Ludovica Migliaccio; Rosario Pascarella; Andrea Zini; Laura Mannismäki; Yannick Béjot; Simon Jung; Henrik Gensicke; Visnja Padjen; Peter A Ringleb; Christian Nolte; Mirjam R Heldner; Patrik Michel; Stefan T Engelter; Sami Curtze; Michael Weller; Susanne Wegener

doi:10.1212/WNL.0000000000207624

IV Thrombolysis With or Without Endovascular Treatment for Suspected Ischemic Stroke in Patients With Intracranial Tumors

Neurology. 2023 Sep 19;101(12):e1241-e1255. doi: 10.1212/WNL.0000000000207624. Epub 2023 Jul 18.

Authors

Katharina Seystahl¹, Nicolas Martinez-Majander², Alexander Salerno², Morin Beyeler², Hebun Erdur², João Pedro Marto², Christian Hametner², Marialuisa Zedde², Alessandro Pezzini², Ronen Leker², Valerian Altersberger², Gianluca Costamagna², Miguel Serôdio², Ludovica Migliaccio², Rosario Pascarella², Andrea Zini², Laura Mannismäki², Yannick Béjot², Simon Jung², Henrik Gensicke², Visnja Padjen², Peter A Ringleb², Christian Nolte², Mirjam R Heldner², Patrik Michel², Stefan T Engelter², Sami Curtze², Michael Weller², Susanne Wegener²

Affiliations

¹ From the Department of Neurology (K.S., M.W., S.W.), Clinical Neuroscience Center, University Hospital and University of Zurich, Switzerland; Department of Neurology (N.M.-M., L. Mannismäki, S.C.), University of Helsinki and Helsinki University Hospital, Finland; Stroke Center (A.S., G.C., P.M.), Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne; Department of Neurology (M.B., S.J., M.R.H.), Inselspital, Bern University Hospital and University of Bern; Graduate School for Health Sciences (M.B.), University of Bern, Switzerland; Department of Neurology (H.E., C.N.), Charité-Universitaetsmedizin Berlin; Center for Stroke Research (CSB) (H.E., C.N.), Berlin; and Berlin Institute of Health (BIH) (H.E., C.N.), Germany; Department of Neurology (J.P.M., M.S.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal; Department of Neurology (C.H., P.A.R.), University Hospital Heidelberg, Germany; Neurology Unit (M.Z.), Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia, Neurology Unit, ASST Spedali Civili, Italy; Department of Neurology (R.L.), Hebrew University Hadassah Medical Center, Jerusalem, Israel; Stroke Center and Department of Neurology (V.A., H.G., S.T.E.), University Hospital Basel and University of Basel, Switzerland; IRCCS Istituto Delle Scienze Neurologiche Di Bologna (L. Migliaccio, A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital, Bologna; Neuroradiology Unit (R.P.), Azienda Unità Sanitaria Locale di Reggio Emilia, Italy; Department of Neurology (Y.B.), University Hospital Dijon, France; Neurology Clinic (V.P.), University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Serbia; Department of Neurology and Neurorehabilitation (S.T.E.), Center for Medicine of Aging and Rehabilitation, University of Basel and University, Felix Platter Hospital, Switzerland. [email protected].
² From the Department of Neurology (K.S., M.W., S.W.), Clinical Neuroscience Center, University Hospital and University of Zurich, Switzerland; Department of Neurology (N.M.-M., L. Mannismäki, S.C.), University of Helsinki and Helsinki University Hospital, Finland; Stroke Center (A.S., G.C., P.M.), Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne; Department of Neurology (M.B., S.J., M.R.H.), Inselspital, Bern University Hospital and University of Bern; Graduate School for Health Sciences (M.B.), University of Bern, Switzerland; Department of Neurology (H.E., C.N.), Charité-Universitaetsmedizin Berlin; Center for Stroke Research (CSB) (H.E., C.N.), Berlin; and Berlin Institute of Health (BIH) (H.E., C.N.), Germany; Department of Neurology (J.P.M., M.S.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal; Department of Neurology (C.H., P.A.R.), University Hospital Heidelberg, Germany; Neurology Unit (M.Z.), Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia; Department of Clinical and Experimental Sciences (A.P.), Neurology Clinic, University of Brescia, Neurology Unit, ASST Spedali Civili, Italy; Department of Neurology (R.L.), Hebrew University Hadassah Medical Center, Jerusalem, Israel; Stroke Center and Department of Neurology (V.A., H.G., S.T.E.), University Hospital Basel and University of Basel, Switzerland; IRCCS Istituto Delle Scienze Neurologiche Di Bologna (L. Migliaccio, A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital, Bologna; Neuroradiology Unit (R.P.), Azienda Unità Sanitaria Locale di Reggio Emilia, Italy; Department of Neurology (Y.B.), University Hospital Dijon, France; Neurology Clinic (V.P.), University Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Serbia; Department of Neurology and Neurorehabilitation (S.T.E.), Center for Medicine of Aging and Rehabilitation, University of Basel and University, Felix Platter Hospital, Switzerland.

Abstract

Background and objectives: IV thrombolysis (IVT) for suspected ischemic stroke in patients with intracranial neoplasms is off-label. However, data on risks of intracranial hemorrhage (ICH) are scarce.

Methods: In a multicenter registry-based analysis within the European Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration, we assessed frequencies of symptomatic and fatal ICH after IVT for suspected ischemic stroke in patients with intracranial tumors by descriptive statistics and analyzed associations with clinical and imaging characteristics by binary logistic regression. Definition of symptomatic ICH was based on the clinical criteria of the European Cooperative Acute Stroke-II trial including hemorrhage at any site in cranial imaging and concurrent clinical deterioration.

Results: Screening data of 21,289 patients from 14 centers, we identified 105 patients receiving IVT; among them were 29 patients (28%) with additional endovascular treatment, with suspected, that is, imaging-based, or histologically confirmed diagnosis of intracranial tumors. Among 104 patients with CT or MRI after IVT available, symptomatic and fatal ICH were observed in 9 and 4 patients (9% and 4%, respectively). Among 82 patients with suspected or confirmed meningioma, symptomatic and fatal ICH occurred in 6 and 3 patients (7% and 4%), respectively. In 18 patients with intra-axial suspected or confirmed primary or secondary brain tumors, there was 1 symptomatic nonfatal ICH (6%). Of 4 patients with tumors of the pituitary region, 2 patients (50%) had symptomatic ICH including 1 fatal ICH (25%). Tumor size was not associated with the occurrence of symptomatic ICH (odds ratio 2.8, 95% CI 0.3-24.8, p = 0.34).

Discussion: In our dataset from routine clinical care, we provide insights on the safety of IVT for suspected ischemic stroke in patients with intracranial tumors, a population that is commonly withheld thrombolysis in clinical practice and prospective trials. Except for a potential high risk of symptomatic ICH after IVT in patients with tumors of the pituitary region, frequencies of symptomatic ICH in patients with intracranial tumors in our cohort seem to be in the upper range of rates observed in previous studies within the TRISP cooperation. These results may guide individual treatment decisions in patients with acute stroke and intracranial tumors with potential benefit of IVT.

Publication types

Multicenter Study
Research Support, Non-U.S. Gov't

MeSH terms

Brain Ischemia* / complications
Brain Ischemia* / diagnostic imaging
Brain Ischemia* / drug therapy
Fibrinolytic Agents / therapeutic use
Humans
Intracranial Hemorrhages / chemically induced
Intracranial Hemorrhages / etiology
Ischemic Stroke* / drug therapy
Pituitary Neoplasms* / complications
Prospective Studies
Stroke* / complications
Stroke* / diagnostic imaging
Stroke* / drug therapy
Thrombolytic Therapy / adverse effects
Treatment Outcome

Substances

Fibrinolytic Agents