Treatment and prevention of venous thromboembolism in patients with brain tumors
- Eudocia Quant Lee, MD, MPH
Eudocia Quant Lee, MD, MPH
- Assistant Professor of Neurology
- Harvard Medical School
- Patrick Y Wen, MD
Patrick Y Wen, MD
- Section Editor — Neurooncology
- Professor of Neurology
- Harvard Medical School
Treatment and prevention of venous thromboembolism (VTE) in patients with primary and metastatic brain tumors is complicated by two conflicting issues. Patients with brain tumors have a substantial risk for developing VTE due to a hypercoagulable state, neurosurgical procedures, and often leg paresis. However, there is concern that antithrombotic agents can precipitate hemorrhage into the tumor with neurological worsening.
The balance between these issues is discussed here. The overall risk, diagnosis, and treatment of VTE in patients with malignancy, as well as risk and treatment of anticoagulant-associated intracerebral hemorrhage, are reviewed separately. (See "Treatment of venous thromboembolism in patients with malignancy" and "Risk of intracerebral bleeding in patients treated with anticoagulants" and "Reversal of anticoagulation in warfarin-associated intracerebral hemorrhage".)
PREVALENCE AND RISK FACTORS
Patients with primary or metastatic brain tumors, as well as malignancies at other sites, have a latent hypercoagulable state that predisposes to thromboembolism, particularly in the postoperative period [1-3]. (See "Risk and prevention of venous thromboembolism in adults with cancer" and "Pathogenesis of the hypercoagulable state associated with malignancy".)
Estimates of the incidence of venous thromboembolism (VTE) consistently show increased relative risk among patients with cancer compared with the general population, particularly in patients with glioblastoma . In prospective studies of patients with malignant glioma, the observed incidence of symptomatic VTE ranges from 17 to 26 percent [5-8].
Although there is clustering of venous thromboembolic events in the postoperative period following craniotomy and during intensive chemotherapy, the risk persists throughout the clinical course . Risk factors for venous thromboembolism in brain tumor patients may include age ≥60 years, obesity, glioblastoma histology, large tumor size, subtotal resection, use of steroids, chemotherapy, neurosurgery within the past two months, the presence of leg paresis, and A or AB blood type [2,3,9-12].
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- PREVALENCE AND RISK FACTORS
- RISK OF INTRACEREBRAL HEMORRHAGE
- Patients with primary brain tumors
- Patients with brain metastases
- Systemic malignancy without known brain metastases
- Treatment with antiangiogenic therapy
- TREATMENT OF VENOUS THROMBOEMBOLISM
- Patients at average risk for bleeding
- - Agent selection
- - Safety
- - Duration of therapy
- Patients at increased risk for bleeding
- - Inferior vena cava filter
- PREVENTION OF VENOUS THROMBOEMBOLISM
- Role of anticoagulation for primary prevention
- Role of daily aspirin
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS