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Case Report
From mechanism to mitigation: Addressing ponatinib’s cerebral arterial occlusion risk
1 Department of Neurology, Barrow Neurological Institute/Creighton University School of Medicine, Phoenix, Arizona, USA
2 Department of Neurology, Ascension Medical Group, Austin, Texas, USA
Address correspondence to:
Supreet Kaur†
Department of Neurology, University of Texas at Austin/Ascension Medical Group, Austin, Texas,
USA
Message to Corresponding Author
Article ID: 100161Z10MO2026
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Harnoor V, Kaur S. From mechanism to mitigation: Addressing ponatinib’s cerebral arterial occlusion risk. J Case Rep Images Oncology 2026;12(2):19–25.ABSTRACT
Introduction: Tyrosine kinase inhibitors (TKIs) have significantly improved outcomes in Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL). Ponatinib, a third-generation TKI active against the T315I mutation, offers superior survival benefits but carries an increased risk of arterio-occlusive events (AOEs), including ischemic stroke, particularly in patients with baseline vascular risk factors. We report a suspected ponatinib-associated large vessel occlusion stroke and discuss potential mechanisms, monitoring, and management considerations.
Case Report: A 60-year-old woman with Ph+ ALL on ponatinib for four years, hypertension, diabetes, hyperlipidemia, and prior deep vein thrombosis presented after waking up with dysarthria, left facial weakness, and hemisensory loss. Imaging revealed acute right parietotemporal infarction with proximal right M2 occlusion. She was initially ineligible for intravenous thrombolysis and endovascular thrombectomy (EVT) because of an absent diffusion-weighted imaging–fluid-attenuated inversion recovery mismatch and a low National Institutes of Health Stroke Scale (NIHSS) score. Overnight, she developed dense left hemiplegia and neglect. Statim (STAT) imaging showed favorable perfusion mismatch prompting emergent EVT, which achieved successful reperfusion. Given negative comprehensive embolic stroke workup and right M2 irregularity on follow-up imaging suggestive of intracranial vasculopathy, prolonged ponatinib exposure and uncontrolled vascular risk factors were considered contributory. Ponatinib was discontinued, and she was discharged to rehabilitation with a modified Rankin Scale score of 4 at two months.
Conclusion: This case highlights a suspected ponatinib-associated large vessel ischemic stroke treated with EVT in a patient with prolonged exposure and multiple vascular risk factors. It underscores the risk of cerebrovascular AOEs during ponatinib therapy and importance of vascular risk assessment, monitoring, and multidisciplinary management to reduce treatment-related morbidity while balancing leukemia control.
Keywords: Arterial occlusion, Cerebrovascular disease, Ponatinib, Thrombectomy,
†All work was performed at the Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona.
SUPPORTING INFORMATION
Acknowledgments
We acknowledge the patient and the excellent clinical team.
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Vishal Harnoor† - Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Final approval of the version to be published
Supreet Kaur† - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guaranter of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
Copyright© 2026 Vishal Harnoor et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
