Anticoagulation after intracranial hemorrhage in brain tumors: Risk of recurrent hemorrhage and venous thromboembolism

Abstract

Background Intracranial hemorrhage (ICH) is a common and often devastating outcome in patients with brain tumors. Despite this, there is little evidence to guide anticoagulation management following an initial ICH event. Objectives To analyze the risk of recurrent hemorrhagic and thrombotic outcomes after an initial ICH event in patients with brain tumors and prior venous thromboembolism (VTE). Patients and Methods A retrospective cohort study was performed. Radiographic images obtained after initial ICH were reviewed for the primary outcomes of recurrent ICH and VTE. Results and Conclusions A total of 79 patients with brain tumors who developed ICH on anticoagulation for VTE were analyzed. Fifty‐four patients (68.4%) restarted anticoagulation following ICH. The cumulative incidence of recurrent ICH at 1 year was 6.1% (95% confidence interval [CI], 1.5‐15.3) following reinitiation of anticoagulation. Following a major ICH (defined as an ICH >10 mL in size, causing symptoms, or requiring intervention), the rate of recurrent ICH upon reexposure to anticoagulation was 14.5% (95% CI, 2.1‐38.35), whereas the rate of recurrent ICH following smaller ICH was 2.6% (95% CI, 0.2%‐12.0%). Mortality following a recurrent ICH on anticoagulation was 67% at 30 days. The cumulative incidence of recurrent VTE was significantly lower in the restart cohort compared to patients who did not restart anticoagulation (8.1% vs 35.3%; P = .003). We conclude that resumption of anticoagulation is lowest among patients with metastatic brain tumors with small initial ICH. Following an initial major ICH, resumption of anticoagulation was associated with a high rate of recurrent ICH.

Venous thromboembolism in children with central nervous system tumors: Comparison of an institutional cohort to a national administrative database

“…Continued monitoring and reporting of VTE rates among this patient population will be important as treatment strategies change drastically over the coming decades, with the maturation of targeted molecular agents and immunotherapies, including cell-based therapies that may be associated with different thrombotic risk than current treatment regimens. Furthermore, given the relatively high rate of hemorrhagic complications in patients with CNS tumors who are on anticoagulation agents, 47,48 decisions about prophylactic anticoagulation should be thoughtfully considered. Further investigations into the risks and benefits of prophylactic anticoagulation in pediatric patients with CNS tumors are warranted.…”

Intracranial hemorrhage with direct oral anticoagulants in patients with brain metastases

“…A recent study of 79 patients with brain tumors demonstrated a high incidence of ICH recurrence and associated mortality after resumption of anticoagulation post-ICH. 16 Additionally, the severity of the initial ICH appeared to directly correlate with the risk of recurrent ICH. In the current study, anticoagulation was continued in ;50% of patients with ICH (Table 3), which is most likely a reflection of the nonsevere clinical presentation and course of these patients.…”

“…Although anticoagulation-related ICH is frequent in these patients, data on clinical presentation, course, and management are also scarce. 16 We aimed to assess the rates of ICH associated with DOACs and LMWH in patients with metastatic brain tumors, test the performance of the PANWARDS score, and evaluate the clinical presentation, management, and course of ICH.…”

2022 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer, including patients with COVID-19

“… 77 In a retrospective cohort of 79 patients with metastatic brain tumours who developed intracerebral haemorrhage on anticoagulation for VTE, the cumulative incidence of recurrent VTE was significantly lower in patients restarting anticoagulation compared with patients who did not (8·1% vs 35·3%; p=0·003). 78 Data from randomised controlled trials comparing the efficacy and safety of direct oral anticoagulants versus LMWHs in patients with brain tumours were limited to three patients included in the SELECT-D trial 25 and 74 patients included in HOKUSAI-VTE Cancer trial. 24 Since the 2019 ITAC guidelines, 5 three retrospective studies assessed the safety of direct oral anticoagulants versus LMWHs in patients with primary or metastatic brain tumours treated for VTE.…”