Top Things to Know: Classification & Management of Ischemic Stroke in Patients with Active Cancer
Published: February 02, 2026
Prepared by Anne Leonard MPH, RN National Senior Director Science and Medicine, American Heart Association
- About 10-15% of patients with ischemic stroke have a history of cancer, one-half of those have an active malignancy at the time of stroke.
- Cancer (about 2 million new cases each year and over 21 million cancer survivors by 2030) is the second and stroke is the fourth leading cause of death in the US. There is a connection between cancer, its treatments, and the vascular system, leading to an increased incidence of acute ischemic stroke (AIS) in patients who harbor or were previously treated for an underlying malignancy.
- Stroke is occasionally the presenting sign of an occult cancer. Anywhere from 1.5%-10% of patients with AIS will be diagnosed with a new malignancy within one year, with cryptogenic mechanisms and dedicated cancer screening conferring higher risks.
- Strokes in this population are typically classified cryptogenic or attributed to cancer-specific mechanisms. These cryptogenic strokes often have characteristic risk markers and clinical features and are extremely high risk for recurrent stroke and other adverse events, distinguishing them from other stroke subgroups. Recent epidemiological, translational, and histopathological data indicate that many of these events are likely caused by cancer itself through multifactorial prothrombotic processes.
- Clinical care reflects the standard approach to any patient with stroke, prior or concurrent cancer frequently changes the pathophysiology and clinical impact of cerebral ischemia, necessitating a different work-up, and extra considerations and vigilance when deciding on thrombolytics, clot retrieval, antithrombotic agents, and future cancer treatments.
- Factors for increased risk of stroke in cancer patients include cancer treatment effects with frequent interruptions in antithrombotic therapy for procedures, thrombocytopenia, and bleeding. Cancer mediated hypercoagulability is the largest factor in stroke in cancer patients.
- Conventional stroke mechanisms account for about half the burden of AIS in patients with active cancer, although cancer-related factors sometimes mediate these mechanisms. Large artery atherosclerosis is a frequent stroke mechanism in the oncological population because of high smoking rates and the long-term effects of cancer treatments.
- Other clinical issues discussed in this statement include diagnostic evaluation, goals of stroke care, acute treatment, recurrent stroke, secondary prevention (both for known and unknown mechanisms).
- This scientific statement proposes a novel classification for ischemic stroke attributed to cancer itself, which would be defined as “cancer-related stroke” and would enable a consistent nomenclature and harmonize stroke classification across clinical practice and research. This system is based on routinely available clinical data and includes different categories for certainty of causality, relating to patient’s distinctive clinical features and estimated risk for recurrent thromboembolism. With this, it will remove it from the ESUS umbrella to enable consistent nomenclature across clinical practice and research.
- Cancer-related stroke is becoming more prevalent and is a high-risk subgroup of AIS. It has distinctive clinical features, mechanisms and outcomes. Cancer treatments are improving and with this the prognosis of cancer-related stroke will improve as well.
Citation
Navi BB, Kasner SE, Cushman M, Okwuosa TM, Fleming NH, Behr JM, Yang JJ, Gupta A, DeAngelis LM; on behalf of the American Heart Association Stroke Council and Council on Cardiovascular and Stroke Nursing. Classification and management of ischemic stroke in patients with active cancer: a scientific statement from the American Heart Association. Stroke. Published online February 2, 2026. doi: 10.1161/STR.0000000000000517