Cerebrovascular complications of cancer

Jai Grewal MD (Dr. Grewal of the Long Island Brain Tumor Center at Neurological Surgery, PC, received research funding from Northwest Biotherapeutics and consulting fees from Novocure.)
Harpreet K Grewal MD (Dr. Grewal of JGMDPC in Roslyn, New York, has no relevant financial relationships to disclose; Dr. Grewal's spouse received research funding from Northwest Biotherapeutics and consulting fees from Novocure.)
Edward J Dropcho MD, editor. (Dr. Dropcho of Indiana University Medical Center has no relevant financial relationships to disclose.)
Originally released September 7, 1994; last updated May 17, 2014; expires May 17, 2017

Overview

Cerebrovascular disease (sinus thrombosis, cerebral infarction, or hemorrhage) is a common complication of cancer and of cancer therapy. In this article, the authors review the clinical milieu in which these disorders develop and summarize the methods of diagnosis, including characteristic abnormalities of clinical findings, coagulation function tests, and neuroimaging. The management of these vascular disorders can be challenging in this patient population because of comorbidities associated with cancer. Some vascular disorders are unique to the cancer patient, including radiation-induced carotid artery atherosclerosis and chemotherapy-induced vasculopathy. Until recently, reports of these latter conditions were anecdotal and infrequent. In recent years, large-scale studies have provided the first index of the frequency of these complications, particularly in lymphoma and breast cancer patients.

Key points

 

• Cancer is a hypercoagulable state leading to an increased risk of venous and arterial thromboembolic events.

 

• Cancer therapies such as radiation and chemotherapy have a range of adverse effects upon the CNS vasculature.

 

• Patients with cancer are also at risk for intracranial hemorrhage from a variety of factors including thrombocytopenia, coagulopathy, and hemorrhagic brain metastases.

Historical note and terminology

In the mid-1800s, Armand Trousseau first drew attention to the clinical association between thrombophlebitis and cancer. Subsequently, clinicians observed that thrombophlebitis is only 1 manifestation of a coagulopathy associated with cancer, which represents a disruption of the delicate balance that normally exists between hemorrhage and coagulation. This coagulopathy is poorly understood, and its mechanism is controversial. Disseminated intravascular coagulation is generally defined as excess thrombin generation within the vasculature that overwhelms normal regulatory hemostatic mechanisms. This results in increased consumption of platelets, coagulation factors, and sometimes inhibitors of coagulation. Defibrination syndrome and consumption coagulopathy are alternate terms for disseminated intravascular coagulation.

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