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Anticoagulation and Intracranial Hemorrhage in Patients with Brain Metastases
Patients with brain metastases present a clinical challenge because they are at increased risk for spontaneous intracranial hemorrhage (sICH) as well as venous thromboembolism (VTE). Is one class of anticoagulation a better choice than another? Can patients with a history of sICH get another chance at anticoagulation?
To address these uncertainties, investigators examined a multinational, retrospective cohort of 505 patients with metastatic brain cancer receiving either a direct oral anticoagulant (DOAC) or low-molecular-weight heparin (LMWH) for VTE or atrial fibrillation.
- Patients receiving DOACs had similar 12-month cumulative incidence of sICH compared with patients receiving LMWH (≈10%), mortality (≈50%), and VTE (≈5%).
- In a multivariable analysis, patients with a history of anticoagulant-associated ICH, a bleeding disorder, concurrent aspirin use, melanoma, and renal cell carcinoma were at higher risk for ICH.
- Nearly one third of patients who stopped anticoagulation resumed it within 90 days, and ICH recurred in only one patient.
Comment
In my hematology practice, I often prescribe DOACs for patients with brain metastases who need anticoagulation. I am reassured by these results: DOACs are as safe as LMWH in this context and save patients from injections. The study also reassures me of the safety of resuming anticoagulation in patients who suffered an ICH and have recurrent VTE. However, we need to approach these patients on a case-by-case basis. I generally stop the concurrent use of aspirin unless there is a strong independent indication, and I am extremely cautious about starting anticoagulation in patients with melanoma or renal cell carcinoma who have brain metastases.
Citation(s)
Author:
Hamulyák EN et al.
Title:
Multinational cohort study of intracranial hemorrhage in patients with brain metastases receiving anticoagulation.
Source:
Haematologica
2025
Jun
; [e-pub].
(Abstract/FREE Full Text)
Empfohlen von
Brady L. Stein, MD, MHS