Cancer prevalence higher in stroke patients than in the general population: the Dutch String-of-Pearls Institute (PSI) Stroke study

Outcomes in ischemic and hemorrhagic stroke patients with cancer: The Japan Stroke Data Bank

INTRODUCTION

Data on the impact of malignancy on outcomes in patients with stroke, especially hemorrhagic stroke, are limited. We aimed to clarify the association between cancer and outcomes for each stroke type (ischemic/hemorrhagic) using a hospital-based multicenter stroke registration database.

PATIENTS AND METHODS

Study participants were adult patients within 7 days of the onset of ischemic stroke (IS) or hemorrhagic stroke (HS) between 2000 and 2020 in the Japan Stroke Data Bank (JSDB). The patients were categorized into two groups according to whether they had a history of cancer. Outcomes included good functional outcomes, representing a modified Rankin Scale score of 0-2 at discharge and in-hospital mortality.

RESULTS

Of the 203,983 patients analyzed in this substudy, 152,591 (women, 39.9 %; median age, 75 years) had IS, and 51,392 (48.6 %; 69 years) had HS. Of these, 6409 IS (4.2 %) and 1560 HS (3.0 %) patients had any cancer. IS patients with cancer had a lower frequency of good functional outcomes (47.5 % vs. 56.3 %; adjusted odds ratio [aOR] 0.85, 95 % confidence interval [CI] 0.79-0.91) and a higher incidence of in-hospital mortality (6.7 % vs. 4.5 %; aOR 1.59, 95 % CI 1.41-1.80) than those without cancer. HS patients with cancer showed a lower frequency of good functional outcome (24.9 % vs. 35.7 %; aOR 0.88, 95 % CI 0.78-0.99) and higher incidence of in-hospital mortality (20.1 % vs. 16.0 %; aOR 1.26, 95 % CI 1.04-1.52) than those without cancer.

CONCLUSIONS

Both IS and HS patients with cancer had significantly lower good functional outcomes and more in-hospital mortality.

Association of Transcranial Doppler Microembolic Signal With Short-Term Mortality in Acute Ischemic Stroke and Active Cancer

BACKGROUND

This study aimed to clarify the characteristics and survival prediction value of transcranial Doppler microembolic signals (MES) in patients with acute cerebral infarction and active cancer.

METHODS AND RESULTS

Between 2017 and 2022, 1089 cases of acute cerebral infarction were recorded within 7 days of disease onset. Among them, transcranial Doppler was successful in 33 patients who had active cancer, and these data were analyzed in this study. The primary outcomes were stroke recurrence and mortality at 3 months. The study population had the following characteristics [median (interquartile range)]: age, 70 years (63-78); body mass index, 21.6 (20-24), National Institutes of Health Stroke Scale 3 (1-6), and modified Rankin Scale score at discharge 1 (1-4). The most common cancer types were lung (24%), pancreatic (24%), and intestinal (18%). MES was present in 16 of 33 patients (48.5%). The presence and number of MES were significantly associated with the levels of D-dimer (P <0.001) and C-reactive protein (P=0.012). Moreover, the presence of MES was associated with multiple ischemic lesions and the 3-territory sign on magnetic resonance imaging. Of the 33 patients, 9 died at 3 months, and 1 had stroke recurrence. On Cox multivariate analysis, using the MES-negative group as a reference, the presence of MES was significantly associated with all-cause death (adjusted hazard ratio, 12.19 [95% CI, 1.45-216.85]; P=0.020).

CONCLUSIONS

In patients with acute ischemic stroke and active cancer, the presence of MES was associated with D-dimer and C-reactive protein levels and multiple and 3-territory ischemic lesions, and was predictive of short-term survival.

Vascular events in patients with head and neck cancer: A systematic review and meta-analysis

OBJECTIVE

To assess the incidence of vascular events in patients with head and neck cancer.

REVIEW METHODS

Primary studies identified through April 2023. Meta-analysis was performed.

RESULTS

There were 146 studies included in the systematic review. Rates of events were collected in the overall group, those with chemoprophylaxis, and those that underwent surgery, radiation, or chemotherapy. Of 1 184 160 patients, 4.3% had a vascular event. Radiation therapy had highest risk of overall events and stroke when compared to surgery and chemotherapy. Chemotherapy had a higher risk of stroke and overall events when compared to surgery.

CONCLUSIONS

Vascular events occur in 4%-5% of patients with head and neck cancer. Our data does not support the use of routine anticoagulation. Patients undergoing radiation therapy had the highest frequency of events.

Clinical analysis of twenty-one cases of acute ischemic stroke related to Trousseau syndrome

BACKGROUND

Trousseau syndrome (TS) is relatively rare and easily overlooked by clinicians, causing misdiagnosis and affecting subsequent treatment.

OBJECTIVE

In this study, clinical features, laboratory examination, imaging features, treatment, and prognosis of patients with TS were discussed.

METHODS AND MATERIAL

From February 2018 to April 2022, cases of 21 patients with malignant tumors complicated by acute ischemic stroke (AIS) were admitted to the Neurology Department of the hospital, and were retrospectively analyzed and discussed based on the literature.

RESULTS

Twenty-one cases were included in the study. Of these, 95.23% (20/21) developed AIS 6-21 months after the onset of malignant tumors, 9.52% (2/21) had ischemic stroke as the first symptom, 4.76% (1/21) had recurrent ischemic stroke, and 14.29% (3/21) subsequently experienced venous and arterial thrombosis events; 80.95% (17/21) were pathologically confirmed to have adenocarcinoma; and 90.47% (19/21) of infarction cases involved multiple blood vessel feeding sites. MRI showed multiregional, multifocal patchy infarcts. D-dimer concentration was higher than normal in all patients. In addition, 61.90% (13/21) of the patients had poor outcomes according to mRS.

CONCLUSION

TS is a rare clinical type. It is often associated with adenocarcinoma, and the treatment is different from that of conventional cerebral infarction and the prognosis is very poor. In clinical practice, for AIS of unknown cause, if MRI shows multiple small lesions accompanied by a significant increase in D-dimer, routine screening for latent malignant tumors is recommended.

Acute ischaemic stroke in active cancer versus non-cancer patients: stroke characteristics, mechanisms and clinical outcomes

BACKGROUND AND PURPOSE

Demographics, clinical characteristics, stroke mechanisms and long-term outcomes were compared between acute ischaemic stroke (AIS) patients with active cancer (AC) versus non-cancer patients.

METHODS

Using data from 2003 to 2021 in the Acute STroke Registry and Analysis of Lausanne, a retrospective cohort study was performed comparing patients with AC, including previously known and newly diagnosed cancers, with non-cancer patients. Patients with inactive cancer were excluded. Outcomes were the modified Rankin Scale (mRS) score at 3 months, death and cerebrovascular recurrences at 12 months before and after propensity score matching.

RESULTS

Amongst 6686 patients with AIS, 1065 (15.9%) had a history of cancer. After excluding 700 (10.4%) patients with inactive cancer, there were 365 (5.5%) patients with AC and 5621 (84%) non-cancer AIS patients. Amongst AC patients, 154 (42.2%) strokes were classified as cancer related. In multivariable analysis, patients with AC were older (adjusted odds ratio [aOR] 1.02, 95% confidence interval [CI] 1.00-1.03), had fewer vascular risk factors and were 48% less likely to receive reperfusion therapies (aOR 0.52, 95% CI 0.35-0.76). Three-month mRS scores were not different in AC patients (aOR 2.18, 95% CI 0.96-5.00). At 12 months, death (adjusted hazard ratio 1.91, 95% CI 1.50-2.43) and risk of cerebrovascular recurrence (sub-distribution hazard ratio 1.68, 95% CI 1.22-2.31) before and after propensity score matching were higher in AC patients.

CONCLUSIONS

In a large institutional registry spanning nearly two decades, AIS patients with AC had less past cerebrovascular disease but a higher 1-year risk of subsequent death and cerebrovascular recurrence compared to non-cancer patients. Antithrombotic medications at discharge may reduce this risk in AC patients.

Cancer screening in hospitalized ischemic stroke patients: a multicenter study focused on multiparametric analysis to improve management of occult cancers

Background/aims

The reciprocal promotion of cancer and stroke occurs due to changes in shared risk factors, such as metabolic pathways and molecular targets, creating a "vicious cycle." Cancer plays a direct or indirect role in the pathogenesis of ischemic stroke (IS), along with the reactive medical approach used in the treatment and clinical management of IS patients, resulting in clinical challenges associated with occult cancer in these patients. The lack of reliable and simple tools hinders the effectiveness of the predictive, preventive, and personalized medicine (PPPM/3PM) approach. Therefore, we conducted a multicenter study that focused on multiparametric analysis to facilitate early diagnosis of occult cancer and personalized treatment for stroke associated with cancer.

Methods

Admission routine clinical examination indicators of IS patients were retrospectively collated from the electronic medical records. The training dataset comprised 136 IS patients with concurrent cancer, matched at a 1:1 ratio with a control group. The risk of occult cancer in IS patients was assessed through logistic regression and five alternative machine-learning models. Subsequently, select the model with the highest predictive efficacy to create a nomogram, which is a quantitative tool for predicting diagnosis in clinical practice. Internal validation employed a ten-fold cross-validation, while external validation involved 239 IS patients from six centers. Validation encompassed receiver operating characteristic (ROC) curves, calibration curves, decision curve analysis (DCA), and comparison with models from prior research.

Results

The ultimate prediction model was based on logistic regression and incorporated the following variables: regions of ischemic lesions, multiple vascular territories, hypertension, D-dimer, fibrinogen (FIB), and hemoglobin (Hb). The area under the ROC curve (AUC) for the nomogram was 0.871 in the training dataset and 0.834 in the external test dataset. Both calibration curves and DCA underscored the nomogram's strong performance.

Conclusions

The nomogram enables early occult cancer diagnosis in hospitalized IS patients and helps to accurately identify the cause of IS, while the promotion of IS stratification makes personalized treatment feasible. The online nomogram based on routine clinical examination indicators of IS patients offered a cost-effective platform for secondary care in the framework of PPPM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-024-00354-8.

Long-term outcomes of mechanical thrombectomy in acute ischaemic stroke patients with concomitant malignancy

Introduction

Patients with cancer (CP) need a different approach to acute ischaemic stroke (AIS) treatment as intravenous thrombolysis (IVT) may be contraindicated. Mechanical thrombectomy (MT) is a treatment of choice for otherwise eligible patients, although the literature on its long-term outcomes in CP is limited.

Aim

Assessing outcomes of MT-treated AIS patients with concomitant malignancy in a year-long follow-up.

Material and methods

The study included 593 MT-treated AIS patients admitted in 2019-2021. The group was divided into CP (defined as a diagnosis of malignancy and undergoing/qualified for cancer treatment within previous 5 years) and a control group. The profile of cardiovascular risk factors, stroke severity and discharge, 90-day and 365-day outcomes were compared between the groups.

Results

CP and controls had a similar profile of cardiovascular risk factors and comparable stroke severity. CP were less frequently treated with IVT (25.7% vs. 59.1%, p < 0.001). There were no differences between the groups in the successful reperfusion rate and occurrence of haemorrhagic complications. Discharge and 90-day outcomes were similar. CP had higher 365-day mortality (48.6% vs. 29.9%, p = 0.024) but the percentage of patients achieving good functional outcome in a year-long observation was comparable.

Conclusions

Treatment with MT seems beneficial for AIS patients with concomitant malignancy both in short- and long-term observation.

Effects of cancer on stroke recurrence and mortality: A single-center retrospective cohort study

Background

Whether patients with stroke and cancer have specific characteristics remains controversial. In addition, research regarding the effects of individual cancer types on stroke outcomes remains scarce. This study investigated the mortality and stroke recurrence rates in patients with stroke and concomitant cancer and evaluated outcome predictors.

Methods

This study retrospectively enrolled 2610 patients in the Taipei Veterans General Hospital Stroke Registry registered from January 2019 to December 2020. A total of 1868 patients were included after excluding those without acute ischemic stroke or hospitalization. The patients were then categorized into the following diagnostic groups: cancer-associated stroke (CAS), stroke and inactive cancer, and stroke without cancer. The discharge mortality rate, 1-year mortality rate, and 1-year stroke recurrence rate were compared. Multiple clinical characteristics and comorbidities-age, sex, stroke severity, coagulopathy, common vascular risk factors, and acute stroke treatment-were also assessed.

Results

A total of 302 (16.2%) patients had concomitant cancer; 39 (2.1%) patients were classified as having CAS and 263 (14.1%) as having stroke with inactive cancer. The baseline characteristics, stroke severity, and type of acute reperfusion therapy were similar among the three groups. However, the stroke recurrence and mortality rates were much higher in the patients with CAS in both short-term and long-term follow-up. The 30-day and 1-year mortality rates for the CAS, inactive cancer, and no cancer groups were 17.9%, 12.5%, and 4.7%, (p < 0.001) and 51.3%, 33.8%, and 12.4%, (p < 0.001) respectively.

Conclusion

Patients with stroke and active cancer had similar stroke severity. However, the 1-year mortality and stroke recurrence rates were higher in these patients than in patients with inactive cancer or the control group.

The crosstalk between Stroke and Cancer: Incidence of cancer after a first-ever cerebrovascular event in a population-based study

OBJECTIVES

To determine the cancer incidence after the first-ever cerebrovascular event (CVE) and compare it to the cancer incidence in the population from the same region.

METHODS

We evaluated 1069 patients with a first-ever CVE (Ischaemic or haemorrhagic stroke and Transient Ischaemic Attack) from a prospective population registry of stroke and transient focal neurological attacks, diagnosed between 2009 and 2011. We conducted a structured search to identify cancer-related variables and case-fatality for a period of 8 years following CVE. Cancer incidence in CVE patients was compared to the North Region Cancer Registry (RORENO).

RESULTS

We found that 90/1069 (8.4%) CVE patients developed cancer after a first-ever CVE. Overall cancer annual incidence rate was higher after a CVE (820/100,000, 95%CI: 619-1020) than in general population (513/100,000, 95%CI: 508-518). In the 45-54 age group cancer incidence post-CVE was 3.2-fold (RR, 95%CI: 1.6-6.4) higher compared to the general population, decreasing gradually in older age-groups. Median time between CVE and cancer was 3.2 years (IQR = 1.4-5.2). Lower respiratory tract and colorectal were the most frequent cancer types. In univariable models, male sex (sHR = 1.78, 95%CI: 1.17-2.72, p = 0.007), tobacco use (sHR = 2.04, 95%CI: 1.31-3.18, p = 0.002) and peripheral artery disease (sHR = 2.37, 95%CI: 1.10-5.13, p = 0.028) were associated to higher cancer risk after CVE. After adjustment, tobacco use (sHR = 1.84, 95%CI: 1.08-3.14, p = 0.026) remained associated to a higher risk of cancer.

CONCLUSIONS

At the population level, patients presenting a first-ever CVE have higher cancer incidence, that is particularly prominent in younger age-groups. Higher cancer incidence, delayed cancer diagnosis and increased mortality post-CVE warrants further research on long-term cancer surveillance in first-ever CVE survivors.

Clinical and Demographic Characteristics, Mechanisms, and Outcomes in Patients With Acute Ischemic Stroke and Newly Diagnosed or Known Active Cancer

BACKGROUND AND OBJECTIVES

Patients with a new diagnosis of cancer carry an increased risk of acute ischemic stroke (AIS), and this risk varies depending on age, cancer type, stage, and time from diagnosis. Whether patients with AIS with a new diagnosis of neoplasm represent a distinct subset from those with a previously known active malignancy remains unclear. We aimed to estimate the rate of stroke in patients with newly diagnosed cancer (NC) and previously known active cancer (KC) and to compare the demographic and clinical features, stroke mechanisms, and long-term outcomes between groups.

METHODS

Using 2003-2021 data from the Acute STroke Registry and Analysis of Lausanne registry, we compared patients with KC with patients with NC (cancer identified during AIS hospitalization or within the following 12 months). Patients with inactive and no history of cancer were excluded. Outcomes were the modified Rankin scale (mRS) score at 3 months and mortality and recurrent stroke at 12 months. We used multivariable regression analyses to compare outcomes between groups while adjusting for important prognostic variables.

RESULTS

Among 6,686 patients with AIS, 362 (5.4%) had active cancer (AC), including 102 (1.5%) with NC. Gastrointestinal and genitourinary cancers were the most frequent cancer types. Among all patients with AC, 152 (42.5%) AISs were classified as cancer related, with nearly half of these cases attributed to hypercoagulability. In multivariable analysis, patients with NC had less prestroke disability (adjusted odds ratio [aOR] 0.62, 95% CI 0.44-0.86) and fewer prior stroke/transient ischemic attack events (aOR 0.43, 95% CI 0.21-0.88) than patients with KC. Three-month mRS scores were similar between cancer groups (aOR 1.27, 95% CI 0.65-2.49) and were predominantly driven by the presence of newly diagnosed brain metastases (aOR 7.22, 95% CI 1.49-43.17) and metastatic cancer (aOR 2.19, 95% CI 1.22-3.97). At 12 months, mortality risk was higher in patients with NC vs patients with KC (hazard ratio [HR] 2.11, 95% CI 1.38-3.21), while recurrent stroke risk was similar between groups (adjusted HR 1.27, 95% CI 0.67-2.43).

DISCUSSION

In a comprehensive institutional registry spanning nearly 2 decades, 5.4% of patients with AIS had AC, a quarter of which were diagnosed during or within 12 months after the index stroke hospitalization. Patients with NC had less disability and prior cerebrovascular disease, but a higher 1-year risk of subsequent death than patients with KC.

Bleeding risk and mortality according to antithrombotic agents' exposure in cancer-related stroke patients: nationwide population-based cohort study in South Korea

BACKGROUND

Ischemic stroke with active cancer is thought to have a unique mechanism compared to conventional stroke etiologies. There is no gold standard guideline for secondary prevention in patients with cancer-related stroke, hence, adequate type of antithrombotic agent for treatment is controversial.

METHODS

Subjects who were enrolled in National Health Insurance System Customized Research data during the period between 2010 and 2015 were observed until 2019. Subject diagnosed with ischemic stroke within six months before and 12 months after a cancer diagnosis was defined as cancer-related stroke patient. To solve immeasurable time bias, the drug exposure evaluation was divided into daily units, and each person-day was classified as four groups: antiplatelet, anticoagulant, both types, and unexposed to antithrombotic drugs. To investigate bleeding risk and mortality, Cox proportional hazards regression model with time-dependent covariates were used.

RESULTS

Two thousand two hundred eighty-five subjects with cancer-related stroke were followed and analyzed. A group with anticoagulation showed high estimated hazard ratios (HRs) of all bleeding events compared to a group with antiplatelet (major bleeding HR, 1.35; 95% confidence interval [CI], 1.20-1.52; p < 0.001). And the result was also similar in the combination group (major bleeding HR, 1.54; 95% CI, 1.13-2.09; p = 0.006). The combination group also showed increased mortality HR compared to antiplatelet group (HR, 1.72; 95% CI, 1.47-2.00; p < 0.001).

CONCLUSIONS

Bleeding risk increased in the anticoagulant-exposed group compared to antiplatelet-exposed group in cancer-related stroke patients. Thus, this result should be considered when selecting a secondary prevention drug.

Insight into the transcription factors regulating Ischemic Stroke and Glioma in Response to Shared Stimuli

Cerebral ischemic stroke and glioma are the two leading causes of patient mortality globally. Despite physiological variations, 1 in 10 people who have an ischemic stroke go on to develop brain cancer, most notably gliomas. In addition, glioma treatments have also been shown to increase the risk of ischemic strokes. Stroke occurs more frequently in cancer patients than in the general population, according to traditional literature. Unbelievably, these events share multiple pathways, but the precise mechanism underlying their co-occurrence remains unknown. Transcription factors (TFs), the main components of gene expression programmes, finally determine the fate of cells and homeostasis. Both ischemic stroke and glioma exhibit aberrant expression of a large number of TFs, which are strongly linked to the pathophysiology and progression of both diseases. The precise genomic binding locations of TFs and how TF binding ultimately relates to transcriptional regulation remain elusive despite a strong interest in understanding how TFs regulate gene expression in both stroke and glioma. As a result, the importance of continuing efforts to understand TF-mediated gene regulation is highlighted in this review, along with some of the primary shared events in stroke and glioma.

Mechanisms of Ischemic Stroke in Patients with Cancer: A Prospective Study

OBJECTIVE

The objective of this study was to examine the pathophysiology of ischemic stroke with cancer.

METHODS

We conducted a prospective cross-sectional study from 2016 to 2020 at 2 hospitals. We enrolled 3 groups of 50 adult participants each. The main group included patients with active solid tumor cancer and acute ischemic stroke. The control groups included patients with acute ischemic stroke only or active cancer only. The patients with stroke-only and patients with cancer-only were matched to the patients with cancer-plus-stroke by age, sex, and cancer type, if applicable. The outcomes were prespecified hematological biomarkers and transcranial Doppler microemboli detection. Hematological biomarkers included markers of coagulation (D-dimer and thrombin-antithrombin), platelet function (P-selectin), and endothelial integrity (thrombomodulin, soluble intercellular adhesion molecule-1 [sICAM-1], and soluble vascular cell adhesion molecule-1 [sVCAM-1]). Hematological biomarkers were compared between groups using the Kruskal-Wallis and Wilcoxon Rank-Sum tests. In multivariable linear regression models, we adjusted for race, number of stroke risk factors, smoking, stroke severity, and antithrombotic use. Transcranial Doppler microemboli presence was compared between groups using chi-square tests.

RESULTS

Levels of all study biomarkers were different between groups. In univariate between-group comparisons, patients with cancer-plus-stroke had higher levels of D-dimer, sICAM-1, sVCAM-1, and thrombomodulin than both control groups; higher levels of thrombin-antithrombin than patients with cancer-only; and higher levels of P-selectin than patients with stroke-only. Findings were similar in multivariable analyses. Transcranial Doppler microemboli were detected in 32% of patients with cancer-plus-stroke, 16% of patients with stroke-only, and 6% of patients with cancer-only (p = 0.005).

INTERPRETATION

Patients with cancer-related stroke have higher markers of coagulation, platelet, and endothelial dysfunction, and more circulating microemboli, than matched controls. ANN NEUROL 2021;90:159-169.

Prognosis of Acute Ischaemic Stroke Patients with Cancer: A National Inpatient Sample Study

Whilst cancer is a risk factor for acute ischaemic stroke (AIS), its impact on AIS prognosis between metastatic and non-metastatic (MC and NMC) disease is poorly understood. Furthermore, the receipt of intravenous thrombolysis (IVT) and endovascular thrombectomy (ET) and their outcomes is poorly researched. AIS admissions from the National Inpatient Sample (NIS) were included (October 2015-December 2017). Multivariable logistic regressions adjusting for a wide range of confounders analysed the relationship between NMC and MC and AIS in-hospital outcomes (mortality, prolonged hospitalisation >4 days and routine home discharge). Interaction terms with IVT and ET were also computed to explore their impact amongst cancer patients. A total of 221,249 records representative of 1,106,045 admissions were included. There were 38,855 (3.51%) AIS admissions with co-morbid cancer: NMC = 53.78% and MC = 46.22%. NMC was associated with 23% increased odds of in-hospital mortality (odds ratio (95% confidence interval) = 1.23 (1.07-1.42)), which was mainly driven by pancreatic and respiratory cancers. This association was entirely offset by both IVT and ET. MC was associated with two-fold increased odds of in-hospital mortality (2.16 (1.90-2.45)), which was mainly driven by respiratory, pancreatic and colorectal cancers. This association was only offset by ET. Both NMC and MC were significantly associated with prolonged hospitalisation and decreased odds of routine discharge. Cancer patients are at higher odds of acute adverse outcomes after AIS and warrant robust primary prevention. IVT and ET improve these outcomes and should thus be offered routinely unless otherwise contraindicated in this group of stroke patients.

Efficacy and safety of intravenous thrombolysis for acute ischemic stroke in cancer patients: a systemic review and meta-analysis

The efficacy and safety of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) in cancer patients remained uncertain due to low level evidence in the latest guideline for AIS. The aim of this study was to assess the efficacy and safety of IVT in cancer patients with stronger evidence. We searched Medline, Embase, CENTRAL and ClinicalTrials.gov until April 2020 for studies reporting outcomes of functional independence, hemorrhagic transformation (HT), symptomatic intracranial hemorrhage (SICH), major bleeding (MB), in-hospital mortality or 3-month mortality after IVT for AIS in cancer patients. For each outcome, the odds ratio between cancer and non-cancer patients, the risk difference between gastrointestinal and other malignancy, and the proportion in cancer patients were calculated. The meta-analysis showed no significant difference between cancer and non-cancer patients in favorable outcome, HT, SICH, MB, in-hospital mortality and 3-month mortality. Furthermore, there's no significant difference between patients with gastrointestinal and other malignancy in favorable outcome, HT, SICH, MB and 3-month mortality. In race-based subgroup analysis, Asians implied greater likelihood of HT and SICH than non-Asians. Therefore, the study confirmed and strengthened the validity of the guideline with stronger evidence that cancer shouldn't be an exclusion criterion of IVT. Inconsistent with the guideline, gastrointestinal malignancy may not remain an absolute contraindication of IVT while Asians implied increased HT and SICH, which needed further exploration.