Reader Response: Clinical Outcome After Endovascular Treatment in Patients With Active Cancer and Ischemic Stroke: A MR CLEAN Registry Substudy

We thank the authors for their contribution to an improved understanding of efficacy and complications of endovascular treatment (EVT) in patients with active malignancy.¹ The findings of the study that patients with active cancer experienced worse outcomes after EVT, even with favorable prestroke function and technical success, is in agreement with data from the ESCAPE and ESCAPE-NA1 trials of EVT. In both these trials, we found that experiencing comorbid cancer was strongly associated with poor functional outcomes according to the modified Rankin scale score in patients at 90 days, despite achieving small final infarct volumes after EVT.^2,3 While these data can help us adjust our expectations regarding post-EVT outcomes in patients with cancer, it remains challenging to identify a subset of these patients for whom EVT would be definitively futile, or even harmful, to justify withholding acute therapy—assuming they are otherwise eligible. In our clinical experience, we have found that treatment decisions become especially complex when the acute stroke evaluation unexpectedly uncovers a potential malignancy, such as an intracranial metastasis. Shared decision-making strategies have proven helpful in such settings, making the uncertain variables clear to the patient or their proxies.⁴