From the Research
Calvarial metastases are not an absolute contraindication for tissue plasminogen activator (tPA) administration in acute ischemic stroke, but they represent a relative contraindication that requires careful clinical judgment. The primary concern is the increased risk of intracranial hemorrhage, as metastatic lesions can be vascular and may bleed when exposed to thrombolytic therapy. The decision to administer tPA should be individualized based on the extent of metastatic disease, the vascularity of the lesions, and the potential benefit of stroke treatment versus bleeding risk. If the metastases are limited to the calvarium (skull vault) without intracranial extension or significant bone destruction, tPA may be considered with caution, as suggested by the most recent study on the topic 1. Patients should be closely monitored for signs of hemorrhage following administration. The standard tPA dosing for acute ischemic stroke is 0.9 mg/kg (maximum 90 mg) with 10% given as a bolus and the remainder infused over 60 minutes, administered within 4.5 hours of symptom onset. A neurology or stroke specialist consultation is strongly recommended before making this decision to carefully weigh the risks and benefits in each individual case, considering the latest evidence on tPA administration in acute ischemic stroke 2.
Some key considerations in this decision include:
- The extent of metastatic disease and the presence of intracranial extension or significant bone destruction
- The vascularity of the lesions and the potential risk of bleeding
- The potential benefit of stroke treatment versus bleeding risk
- The need for close monitoring for signs of hemorrhage following tPA administration
- The importance of a neurology or stroke specialist consultation to weigh the risks and benefits in each individual case
It is also important to note that the prognosis of patients with calvarial metastases mainly depends on the treatment of the primary disease and the situation of important organ dissemination and treatment, as highlighted in a recent study 1. Therefore, a comprehensive approach to patient care is essential in these cases.