Antithrombotic therapy for secondary stroke prevention in patients with cancer: a systematic review and network meta-analysis.

BACKGROUND

The risk of stroke among patients with cancer is two times that of the general population due to a combination of cancer-, chemotherapy-, radiotherapy-, and surgery-related factors. There is a paucity of data regarding the optimal antithrombotic therapy for secondary stroke prevention in these patients.

OBJECTIVES

Our goal was to review the stroke recurrence in patients treated with different antithrombotic therapies (antiplatelets, warfarin, heparin, and direct oral anticoagulants). Our secondary objective was to review the bleeding risk across different antithrombotic therapies.

METHODS

A review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles that adequately assessed secondary prevention of stroke in patients with cancer were selected from the PubMed, Embase, and Scopus databases from inception until March 2, 2025. We performed a network meta-analysis for stroke recurrence, major bleeding, and mortality. The treatments were ranked by P-SCORE. Subgroup analyses were conducted based on median D-dimer levels, multiple territories of stroke, and exclusion of studies with high risk of bias.

RESULTS

We included 11 studies (four RCTs, six retrospective studies, and one case series) with a total of 1319 patients. In the primary analysis, antiplatelets were the highest-ranked treatment for reducing stroke recurrence (RR 0.44 [0.20; 0.96]), followed by LMWH (RR 0.50 [0.26; 0.96]), both significantly superior to no treatment. However, LMWH consistently ranked higher than antiplatelets in all subgroup analyses. There was no difference regarding major bleeding or mortality.

CONCLUSION

Antiplatelets can be considered an option for secondary prevention of stroke in patients with cancer, especially in patients with a higher bleeding risk. Future research with high-quality studies is needed to confirm our preliminary findings and should focus on identifying subgroups of patients with cancer who may benefit most from specific antithrombotic therapies.