Although hematological diseases generally represent a relatively uncommon cause of stroke, an elevated risk of cerebrovascular complications has been observed in patients with these conditions.1 In a 2019 study of patients with myeloproliferative neoplasms (MPNs), for example, the 5-year risk of vascular disease was 0.5%-7.7%, and adjusted hazard ratios were increased by 1.3- to 3.7-fold among these individuals compared to the general population.2 Stroke may be the first indication of an underlying MPN, according to a paper published online in the Journal of Neurology.1
Additionally, leukemias can lead to ischemic or hemorrhagic strokes. Cerebral venous thrombosis (CVT) is the most frequent cause of cerebral infarction occurring around the time of diagnosis in acute lymphoblastic leukemia, with risk factors including l-asparaginase treatment, high-dose steroids, and intrathecal methotrexate. In patients with acute promyelocytic leukemia – in whom intracerebral hemorrhage is especially common – the use of all-trans retinoic acid represents the main risk factor for CVT.1
In a 2018 analysis based on the 2012 National Inpatient Sample consisting of more than 7 million hospital admissions, researchers found a 50-fold increase in stroke risk among patients with active acute myeloid leukemia (AML) compared to other patients in the sample.3
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The results further revealed higher mortality rates among AML patients with stroke compared to other patients (36.9% vs 6.7%; odds ratio, 5.5; 95% CI, 2.3-8.8; P <.0001). Significant predictors of stroke included “acute renal failure with tubular necrosis, hypernatremia, urinary tract infection, and secondary thrombocytopenia,” wrote the study authors.3
A heightened risk of cerebrovascular accidents has also been observed in patients with lymphomas, multiple myeloma, sickle cell anemia, and various other hematological diseases. Along with increasing risk due to the pathogenesis of these diseases, the iatrogenic effects of associated therapies are a common cause of such events.1
Management of stroke in these individuals “requires close cooperation between hematologists, neurologists, neuroradiologists, and sometimes neurosurgeons,” the study authors stated.1 “Acute stroke treatment is often a dual emergency, as the patient needs both immediate treatment for the neurovascular disturbance and for the underlying hematological condition.”
To further discuss the risk and treatment of cerebrovascular events in this population, we spoke with Nduka Amankulor, MD, assistant professor of neurological surgery and director of the adult neurosurgical oncology program at the University of Pittsburgh School of Medicine, director of the Brain Tumor Immunogenetics Laboratory at the UPMC Hillman Cancer Center.
