What is the most important thing to assure before performing a thrombectomy on a 35-year-old female patient with a significant family history of malignancy, including colonic and breast cancer?

Pre-Thrombectomy Assessment in a 35-Year-Old Female with Family History of Malignancy

The most critical preoperative consideration before thrombectomy is confirming no recent stroke in the patient's history, but equally important is assessing for active malignancy given her significant family history, as active cancer substantially increases both thrombotic and hemorrhagic complications. 1

Essential Preoperative Assessments

Stroke History Verification

• Obtain detailed history of any prior cerebrovascular events, including transient ischemic attacks, as previous stroke significantly impacts procedural risk and outcome expectations 2
• Document timing of any prior neurological events, as recent stroke may alter the risk-benefit calculation for mechanical thrombectomy 3
• Review prior neuroimaging if available to assess for chronic infarcts or hemorrhagic transformation risk 3

Cancer Screening Given Family History

• Active malignancy must be ruled out or confirmed, as patients with active cancer have significantly higher mortality rates post-thrombectomy compared to those in remission (though the procedure remains safe and efficacious) 1
• Given her family history of colonic and breast cancer, assess for any symptoms suggesting occult malignancy: unexplained weight loss, changes in bowel habits, breast masses, or constitutional symptoms 4
• Active cancer increases VTE risk six-fold and substantially elevates both thrombotic and bleeding complications perioperatively 5

Coagulation Assessment

• Obtain comprehensive coagulation studies: PT, aPTT, platelet count, and consider testing for acquired coagulopathies 6
• Assess bleeding history specifically: spontaneous bruising, excessive surgical bleeding, menorrhagia, or family history of heritable coagulopathies 6
• These tests identify previously undetected disorders of hemostasis that could increase procedural bleeding risk 6

Critical Risk Stratification

If Active Cancer is Present

• Thrombectomy remains indicated and effective, but mortality rates are significantly higher in patients with active cancer versus those in remission 1
• The procedure should not be withheld based on cancer status alone, as functional outcomes at 90 days do not significantly differ between active cancer and cancer-free patients 1
• Enhanced post-procedural surveillance for both thrombotic and hemorrhagic complications is warranted 1

Procedural Complications to Anticipate

• Overall risk of complications with sequelae is approximately 15% from mechanical thrombectomy 3
• Major complications include: symptomatic intracerebral hemorrhage, subarachnoid hemorrhage, arterial perforation/dissection, vessel injury, and embolization to new territories 3
• Access-site complications (hematoma, vessel injury) and device-related complications (vasospasm, dissection) require immediate recognition and management 3

Common Pitfalls to Avoid

• Failing to assess for active malignancy in patients with strong family history, as this substantially alters risk stratification and post-procedural management 1
• Excluding patients from thrombectomy based solely on age or comorbidities without individualized assessment of stroke severity and functional baseline 2
• Inadequate coagulation assessment, particularly failing to obtain bleeding history which may reveal occult coagulopathies not detected by routine testing 6
• Not preparing for enhanced post-procedural monitoring in high-risk patients (those with active cancer, multiple comorbidities) 1, 3