Table 2.

Pros and Cons of Anticoagulant or Antiplatelet Therapy for Cancer-Associated Ischemic Stroke

Anticoagulants

Pros

Some studies suggest that they may reduce D-dimer levels, TCD microemboli, and short-term recurrent events in cancer patients with ischemic stroke

More directly addresses cancer-mediated hypercoagulability, especially LMWHs, which have more “off-target” anticoagulant effects than direct oral anticoagulants

LMWHs, in particular, may have some anti-neoplastic properties, explaining their superiority to vitamin K antagonists for treating cancer-associated venous thromboembolism

Cons

Higher bleeding risk than with antiplatelets, especially intracranially, which could outweigh any potential reductions in recurrent stroke risk

Expensive, especially LMWHs and the direct oral anticoagulants

LMWH forms are burdensome injectables that can be difficult to administer for cancer-stroke patients, hindering adherence

Antiplatelets

Pros

Standard-of-care for most stroke patients; Level 1 evidence supporting their use

Excellent safety profile

May have direct anti-neoplastic properties through inhibition of tumor growth and spread

Inexpensive

Once daily oral administration

Cons

Less aggressive blood thinning, which might not sufficiently address cancer-mediated hypercoagulability and its contribution to stroke risk

Aspirin, in particular, increases the risk of gastrointestinal ulcers and bleeding

Abbreviations: TCD, transcranial Doppler; LMWH, low-molecular weight heparin.