Blood journal Oct 2024
ICH risk factors in pt with brain tumors receiving anticoagulation(ACN)-Table 1
1. High risk: plt count < 50K, large vol ICH (> 10 ml)
2. Intermediate risk: High grade glioma, plt < 100K, combining antiplatelet therapy with anticoagulation.
3. Uncertain risk: SRS( except melanoma) VEGF inhibitors, CKD
Other useful tips
1. 4 types of ca with high risk of ICH even without ACN- melanoma, RCC, thyroid, choriocarcinoma
2. VEGF inhibitors can increase risk of bleeding in gliomas.
3. Use DOAC for ACN in glioma, not LMWH.
4. Antiplatelets alone do not increase risk of ICH in brain tumors
5. Pre-existing intratumoral hemorrhage
Case scenarios:
1. Pt with high grade glioma, new PE, recent tumor related ICH in the last 30 days ( yes or no): what are the risk factors for bleeding and progressive thrombosis.
Estimate risk for bleeding: concurrent antiplatelet use, reduced plt count, type of tumor, high grade glioma, large vol or multifocal ICH, recent SRS ( esp melanoma), what does the most recent brain imaging show ( stable hemosiderin deposition is good)
Assessment: The brain mets are stable or tumor risk of bleeding is high/ intermediate. Other risk factors that increase risk of bleeding include:
While these risk factors increase risk of ICH, the risk is not prohibitive, start LMWH ( or DOAC for glioma), monitor in neuro ICU, repeat CT in 24-48 hr.
If risk is prohibitive because of high risk of bleeding, and the thrombotic risk is high ( PE or proximal DVT)--> place a filter
2. Recent tumor related ICH in the last 30 days
If isolated subsegmental PE ( neg b/l DVT), then OK to withold AC until stable, then repeat US in 1 week and 2 weeks. If propagation, consider ACN if bleed has stabilized.
If proximal VTE, PE and high risk of ICH expansion ( high vol > 10 ml ICH), IVC filter, hold ACN
If intermediate risk ICH expansion--> LMWH or DOAC 50% dose start typically after 2-4 days.
Discuss risk benefit ratio with healthcare proxy and document discussion.
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