Anticoagulation Tied to Higher Risk of Brain Hemorrhage in Cancer Patients With Brain Metastases

By Reuters Staff

March 17, 2021

NEW YORK (Reuters Health) - Anticoagulation is associated with an increased risk for clinically significant intracerebral hemorrhage (ICH) in cancer patients with brain metastases, particularly those with melanoma brain metastases and previous ICH, new research indicates.

"Clinicians should weigh the risk of ICH versus the strength of the indication to anticoagulate when managing patients with indications for anticoagulation, and such decisions should be integrated into a broader discussion of each patient's specific goals of care," the researchers advise in the Journal of Neurology, Neurosurgery and Psychiatry.

Cancer patients, especially those with brain involvement, are predisposed to develop venous thromboembolism, requiring therapeutic anticoagulation, but whether to anticoagulate is "controversial" given the possibility of ICH, Dr. Ayal Aizer with Dana-Farber Cancer Institute in Boston and colleagues note in their article.

To investigate, they did a matched, retrospective study of 291 cancer patients with brain metastases managed at Brigham and Women's Hospital/Dana-Farber Cancer Institute. One hundred received therapeutic anticoagulation and 191 did not. Before anticoagulation, the risk of ICH was comparable in both groups.

Post-anticoagulation there were "significant or borderline-significant associations" between anticoagulation and any ICH (hazard ratio 1.31), ICH identified on gradient echo/susceptibility-weighted imaging, the most sensitive way to detect ICH (HR, 1.46), symptomatic ICH (HR, 1.80), extralesional ICH (HR, 5.82) and ICH leading to death (HR, 5.68).

The risk of ICH was higher in those with than without prior ICH (HR, 2.20) and in those with melanoma (versus other primary malignancies, HR, 6.46).

The authors of a linked editorial say this study addresses an issue of "high clinical interest in a well-performed matched control cohort study in patients with brain metastases of different origins receiving therapeutic anticoagulation."

The results "can be useful in clinical decision-making and evaluation of individual patients' bleeding risk," write Dr. Anna-Katharina Meissner and Dr. Maximilian Ruge of the University of Cologne, in Germany.

The significantly higher rate of bleeding detected by SWI/GRE imaging suggests that "highly sensitive imaging may be beneficial and should be integrated in the clinical routine workflow," they suggest.

"A further question that remained open at the end is, whether a difference in bleeding risk exists depending on the type of anticoagulation (warfarin, DOACS, heparin) administered. A significant difference would be of high clinical impact for the choice of anticoagulation therapy, especially in the subpopulations detected to be at risk. Due to the small patient subsets receiving different medications, the presented study was not empowered to answer this question. Therefore, it would be desirable to focus on this promising issue in further studies with larger numbers of patients and carefully conducted matching algorithms," the editorialists conclude.

The study had no specific funding.

SOURCE: and Journal of Neurology, Neurosurgery and Psychiatry, online March 10, 2021.