Background: Cancer patients are at an increased risk for ischemic and hemorrhagic strokes. Ischemic stroke in this population often presents with distinctive features, such as cryptogenic etiology and multiple ischemic lesions, and is driven by cancer-associated coagulopathy, complicating management strategies. Methods: We reviewed current literature on intravenous thrombolysis (IVT) for acute ischemic stroke in cancer patients through PubMed search with no time limits. We included international guidelines, meta-analyses, cohort studies, and case series to evaluate its safety and efficacy. This descriptive review aims to evaluate the risks and benefits of thrombolytic treatment in patients with acute stroke and cancer. Discussion: Despite limited high-quality evidence (no randomized trial), studies suggest that IVT is generally safe and effective in cancer patients with ischemic stroke. However, treatment should be individualized, considering specific contraindications and the patient’s tumor characteristics. The 2019 American Heart Association/American Stroke Association guidelines contraindicate IVT in patients with gastrointestinal or intra-axial tumors; conversely, these conditions are not explicitly mentioned in the 2021 European Stroke Organization guidelines, as recent studies have not proven them to be at higher risk per se. Particular attention should be given to coagulation abnormalities, recent surgery, and concomitant medications. Thus, cautious and multidisciplinary management is needed. Further research is essential to define risk stratification for this complex population better. Multicentered, well-designed prospective studies are crucial and should also differentiate patients based on tumor site, histology, and molecular characteristics that could impact both thrombotic and hemorrhagic risk.
