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Cerebrovascular Complications of Cancer
As cancer and stroke are the second and fifth leading causes of mortality in the United States, it is not surprising to encounter a patient with these concomitant diagnoses . Various cerebrovascular disorders can occur within the oncological population, complicating the overall clinical course, treatment, and long-term outcome of cancer patients. Detailed investigation and precise diagnosis of cerebrovascular disorders in cancer patients is important for several reasons. Early recognition of acute stroke may allow the cancer patient access to interventional thrombolytic, surgical, and endovascular therapies, and improve overall patient outcome. Secondary stroke prevention therapies are also guided by the etiology of the particular cerebrovascular event. Additionally, diagnostic workups in young or cryptogenic stroke patients without overt cancer can lead to the first recognition of the underlying malignancy. This chapter presents an overview of cerebrovascular complications from cancer .
Stroke Directly Due to Tumor
Intratumoral Parenchymal Hemorrhage
Intracranial hemorrhage into brain tumors is a relatively frequent occurrence, reported in 1.7–9.6% of all intracranial hemorrhages. Metastatic tumors are more often associated with hemorrhage than are primary tumors . The most common primary central nervous system (CNS) malignancies associated with intratumoral hemorrhage are oligodendroglioma, glioblastoma, and germ-cell tumors. Regarding metastatic malignancies associated with hemorrhage, three of the most common culprits are melanoma, lung cancer, and choriocarcinoma . The diagnosis of thyroid metastases is a suggested consideration in a patient with multiple hemorrhagic masses ( Fig. 112.1 ). Predisposing factors associated with intratumoral hemorrhage include head trauma, hypertension, coagulopathy, shunting procedures, and anticoagulation . Histological factors associated with intratumoral hemorrhage include rapid tumor growth, tumor necrosis, vessel thrombosis, the presence of multiple thin-walled vessels, and tumor invasion of adjacent cerebral vessels/vessel wall degeneration . Patients with parenchymal hemorrhage associated with brain metastases can benefit from steroids and external radiation to reduce cerebral edema. Surgical evacuation of a single hematoma also may be helpful.
Subdural Hemorrhage
Subdural hematomas have been reported in association with a wide variety of malignancies, but typically tend to occur with dural tumor metastases . Neoplastic infiltration of the dura typically results either from hematogenous spread of tumor via dural vessels or from direct extension of skull metastases. Histologically, the tumors most frequently associated with subdural hematoma include gastric carcinoma, prostate carcinoma, breast cancer, leukemia, and lymphoma . Histological examination of the dura with biopsy or cytology studies of the subdural fluid is necessary to confirm the tumoral origin of the subdural hematoma. Treatment of dural metastatic–associated hemorrhage is palliative, including drainage of subdural fluid and brain radiation therapy . If a cancer patient with subdural hematoma undergoes surgical treatment, an adequate biopsy of the dural membrane should be obtained. Radiation therapy should then be administered once the diagnosis is confirmed .
Neoplastic Infiltration of Vessels
Venous Infiltration
Thrombosis of cerebral veins or dural sinuses is a rare event in any patient population, including the oncological population. When obstruction of cerebral venous drainage in cancer patients occurs, a frequent culprit is invasion or compression of cortical veins or dural sinuses by tumor . The most common sinus affected by metastases is the superior sagittal sinus . A variety of malignancies have been reported in association with sinus thrombosis, including leukemia, lymphoma, neuroblastoma, breast carcinoma, lung carcinoma, cervical carcinoma, gallbladder carcinoma, Ewing’s sarcoma, and myeloma . The proposed mechanism for dural sinus thrombosis is also similar to that of subdural hematoma: skull or dural metastases infiltrate or compress the sinus, producing stasis, thrombosis, and occlusion . Heparin has been beneficial in reducing morbidity and mortality in patients with sinus thrombosis without cancer. Radiation therapy should be a consideration in patients with superior sagittal sinus occlusion due to tumor invasion .
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