If the patient with a history of a solid tumor has neurological symptoms such as headaches, change in vision, history of seizures, or concerning findings on physical exam (focal neurological deficit), then imaging should be obtained prior to anticoagulation.

With respect to preventing VTE in patients with brain tumors, there is some limited data suggesting full dose aspirin may be useful although no formal recommendations have been made.3

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Patients in the postoperative period are at the highest risk for VTE, therefore early ambulation and compression stockings in conjunction with enoxaparin or heparin are typically used unless there are medical contraindications to using these medications.3

Inferior vena cava (IVC) filters used to be more commonly used in patients with brain tumors, however complication rates have consistently been higher than those associated with anticoagulation.4,5 Patients with brain tumors who are anticoagulated with warfarin have been reported to have fewer complications than those with IVC filters,5 although most of the data is not derived from head-to-head trials.

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Many studies evaluating warfarin have shown a similar to slightly higher risk (approximately 2% to 7%) of ICH when compared to the baseline bleeding risk of these patients.6 Low molecular weight heparin (enoxaparin) is usually the preferred agent in treating VTE in patients with cancer, however there is substantially less efficacy and safety data in patients with brain tumors. 

As with many decisions in patients with cancer, the choice to anticoagulate is multifactorial. A detailed risk–benefit analysis must be performed with both the patient and health care provider.

The careful and delicate balance between anticoagulation and the risk for bleeding must be heavily considered. Consultation with neurosurgery, neurology, hematology, oncology, and radiology may provide useful information to help aid in the ultimate decision.

References

  1. Semrad TJ, O’Donnell R, Wun T, et al. Epidemiology of venous thromboembolism in 9489 patients with malignant glioma. J Neurosurg. 2007;106(4):601-608.
  2. Simanek R, Vormittag R, Hassler M, et al. Venous thromboembolism and survival in patients with high-grade glioma. Neuro Oncol. 2007;9(2):89-95.
  3. Iorio A, Agnelli G. Low-molecular-weight and unfractionated heparin for prevention of venous thromboembolism in neurosurgery: a meta-analysis. Arch Intern Med. 2000;160(15):2327-2332.
  4. Wen PY, Marks PW. Medical management of patients with brain tumors. Curr Opin Oncol. 2002;14(3):299-307.
  5. Levin JM, Schiff D, Loeffler JS, et al. Complications of therapy for venous thromboembolic disease in patients with brain tumors. Neurology. 1993;43(6):1111-1114.
  6. Schiff D, DeAngelis LM. Therapy of venous thromboembolism in patients with brain metastases. Cancer. 1994;73(2):493-498.

Topics:

Brain Cancer Breast Cancer Glioblastoma In The Clinic Lung Cancer Melanoma Renal Cell Carcinoma Thromboembolism Thyroid Cancer