Beyond Ocular Toxicity: Cerebrovascular Events After Intra-Arterial Chemotherapy for Retinoblastoma.

Background

Cerebrovascular accidents (CVAs) are among the most serious complications of intra-arterial chemotherapy (IAC) for retinoblastoma (RB). This study evaluated the incidence and potential risk factors of this rare event.

Methods

A retrospective cohort study included RB patients who received IAC at a tertiary cancer center. Diagnosis of CVAs was based on clinical and/or neuroimaging findings. Data included demographics, tumor features, complications, and outcomes. Meta-analysis was not feasible due to heterogeneity. A systematic review following PRISMA guidelines was conducted across major databases up to December 2025, including studies reporting CVA after IAC.

Results

The cohort included 33 children who underwent 104 IAC procedures (Melphalan). CVA occurred in three patients (3/33 (9%) of patients, and 3/104 (2.9%) of procedures). Two were confirmed by neuroimaging, while one was a transient ischemic attack. Two patients (67%) were girls, and 2 of 3 (67%) were younger than 1 year. All events occurred during the IAC procedure and were ipsilateral to the treated eye. Two patients had no residual neurological deficits, while one showed improvement with only a minor residual deficit. The systematic review included 14 studies with 932 patients and identified 11 CVA events (1.2%; Range 0-9.1% per patient and 0-2.2% per IAC procedure). All were ischemic with variable presentations. Younger age, repeated catheterization, vasospasm, and embolic events were common risk factors. Outcomes were generally favorable.

Conclusions

CVA after IAC, though rare, may be underreported. Events are likely procedure-related and influenced by age, treatment intensity, and vascular toxicity. Careful technique, close monitoring, and standardized reporting are needed to recognize/reduce the real risk.