The primary aim of this study was to ascertain the optimal antithrombotic therapy for secondary stroke prevention of cryptogenic strokes in cancer patients. 

Cryptogenic ischemic stroke in cancer patients poses a unique clinical management challenge due to the dual risk of stroke recurrence and significant bleeding complications. On one hand, cancer itself is associated with a state of hypercoagulability in which anticoagulation might be superior to antiplatelet therapy. On the other hand,  cancer and its treatments predispose patients to bleeding, a major concern for anticoagulation.

We conducted a systematic review and network meta-analysis, searching PUBMED, EMBASE, and Web of Science from their inception to September 25, 2023. We included studies involving patients with stroke concurrent to active cancer who were treated with antithrombotic drugs. The drugs evaluated in this study were antiplatelets, Low Molecular Weight Heparin (LMWH), warfarin, and NOACs. Our primary endpoint was stroke recurrence, and the secondary endpoint was major bleeding. This study is registered with PROSPERO, CRD42023394773. 

Out of 4113 screened articles, 10 studies with 1201 patients were included. Stroke recurrence was lower in patients using antiplatelets when compared with no therapy (OR 0.39 [0.17-0.89]). Interestingly, the stroke recurrence was similar in patients who used antiplatelets, LMWH, warfarin or NOACs. We found a similar risk of major bleeding in all antithrombotic strategies. 

Similar to non-cancer patients, antiplatelets are as effective as anticoagulants for preventing recorrence of cryptogenic stroke.