The insightful letter by Babakhanlou et al. [ ] captured our attention as the authors pointed out to the lack of clear guidelines for the evaluation and diagnosis of minor head injuries in cancer patients undergoing treatment with vascular endothelial growth factor (VEGF) inhibitors who seek emergency care. While the authors highlight that VEGF inhibitors are associated with an increased risk of bleeding, there remain several issues regarding cerebrovascular events in the contemporary landscape of cancer treatment that demand attention and consideration.

Firstly, the recent widespread use of immunotherapeutic agents and VEGF inhibitors, such as ipilimumab, blinatumomab and bevacizumab, has sparked concerns among clinicians due to the potential of neurologic adverse events [ ]. One of the hallmarks is toxic encephalopathy, which can present with a range of symptoms including dizziness and somnolence or severe symptoms such as confusion, dysphasia, and falls and resultant head injuries. These immune-related adverse events may also include rare but severe complications, including cerebellar dysfunction, Guillain-Barre syndrome, myasthenia gravis, and aseptic meningitis [ , ].

Secondly, given the potential thrombotic and bleeding risks associated with targeted and immunotherapy, it is not uncommon for cancer patients to present to the emergency department with cerebrovascular events, such as strokes or transient ischemic attacks [ , ]. In clinical phase I/II trials conducted at the National Cancer Institute in the United States, ischemic stroke and intracranial hemorrhage occurred at a rate of 1.9% and 1.9%, respectively, in patients receiving bevacizumab. Intracranial hemorrhage was reported to occur in 3.8% of patients receiving VEGF receptor tyrosine kinase inhibitors [ ]. These findings highlight the importance of close monitoring and better assessment of potential risks associated with targeted and immunotherapy.

Thirdly, prompt and efficient assessment and management are imperative for cancer patients exhibiting symptoms of cerebrovascular events. If complications are suspected, patients should be ideally assessed in centers providing the necessary expertise to achieve the best possible outcome [ , ]. Treatment decision should always incorporate patients’ wishes and their overall prognosis.

In summary, the advent of cutting-edge cancer treatments has given rise to a multitude of neurovascular adverse effects. These new therapies have shed light on the underlying causes, mechanisms, and patterns of cerebrovascular events. To effectively diagnose and manage these complex events, it is essential for oncologists, neurologists, and emergency physicians to work in close coordination and provide prompt and competent care. With the rapid progress in the field of cancer therapy, it is more important than ever to stay ahead of the curve and stay prepared to address the neurovascular challenges posed by these treatments.

References

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