Antithrombotic use patterns for secondary stroke prevention in ischemic stroke patients with active malignancy: The STOP-SPAM study.

BACKGROUND: Cancer-associated stroke is increasingly recognized as a distinct ischemic stroke subtype linked to malignancy-related hypercoagulability. Optimal secondary prevention is uncertain, and antithrombotic practice varies. We examined treatment patterns and compared outcomes of anticoagulation versus antiplatelet therapy in patients with active cancer and ischemic stroke. METHODS: We retrospectively studied adults with active malignancy and ischemic stroke at a single academic center (2015-2021). Patients were grouped by physician-selected antithrombotic regimen. Univariable logistic regression identified factors associated with anticoagulant use. Comparative effectiveness and safety were assessed with competing-risk survival analysis using inverse probability of treatment weighting. The primary outcome was recurrent ischemic stroke within 180 days. RESULTS: Among 311 patients, 237 (76.2%) received antiplatelets and 69 (22.2%) anticoagulation. Anticoagulated patients more often had metastatic cancer, multi-territory infarction, and higher NIHSS. Metastatic disease (OR 8.39, 95% CI 3.86-18.25) and combined anterior/posterior circulation infarction (OR 5.77, 95% CI 3.23-10.31) were strongly associated with anticoagulant selection. After weighting, anticoagulation was associated with lower recurrent stroke risk at 180 days versus antiplatelets (sHR 0.31, 95% CI 0.19-0.52). Major bleeding (13.0% vs 5.1%), venous thromboembolism (23.2% vs 5.5%), and mortality (55.1% vs 25.7%) were higher with anticoagulation, likely reflecting greater disease burden. CONCLUSIONS: Clinicians preferentially used anticoagulation in patients with features suggesting hypercoagulability. Anticoagulation was associated with lower recurrent stroke risk but higher bleeding rates. Prospective studies are needed to define optimal secondary prevention.