Laura and Isaac Perlmutter Cancer Center, New York University, New York, New York, USA
Laura and Isaac Perlmutter Cancer Center, New York University, New York, New York, USA.
Oncologist. 2018 Apr;23(4):468-473. doi: 10.1634/theoncologist.2017-0274. Epub 2017 Nov 20.
Patients with primary or metastatic brain tumors are at increased risk of developing venous thromboses. However, the potential benefit of therapeutic anticoagulation in these patients must be weighed against the deadly complication of intracranial hemorrhage. In this review, we summarize available evidence and recent studies of intracranial bleeding risks in primary and metastatic tumors and the impact of therapeutic anticoagulation. We find that for the majority of primary and treated metastatic brain tumors, the risk of spontaneous bleeding is acceptable and not further increased by careful therapeutic anticoagulation with low molecular weight heparin or direct oral anticoagulants, although thrombocytopenia (platelet count less than 50,000/μL) and other coagulopathies are relative contraindications. Patients with brain metastasis from melanoma, renal cell carcinoma, choriocarcinoma, thyroid carcinoma, and hepatocellular carcinoma have a higher tendency to bleed spontaneously than noted in patients with other malignancies, and thus warrant routine brain imaging and alternative strategies such as inferior vena cava filter placement in the acute setting of venous thromboembolism before consideration of therapeutic anticoagulation.
Malignant gliomas are associated with increased risks of both venous thromboses and intracranial hemorrhage, but the additional bleeding risk associated with therapeutic anticoagulation appears acceptable, especially after treatment of primary tumors. Most patients with treated brain metastasis have a low risk of intracranial hemorrhage associated with therapeutic anticoagulation, and low molecular weight heparin is currently the preferred agent of choice. Patients with untreated brain metastasis from melanoma, renal cell carcinoma, thyroid cancer, choriocarcinoma, and hepatocellular carcinoma have a higher propensity for spontaneous intracranial bleeding, and systemic anticoagulation may be contraindicated in the acute setting of venous thromboembolism.
患有原发性或转移性脑肿瘤的患者发生静脉血栓的风险增加。然而，必须权衡这些患者接受治疗性抗凝治疗的潜在益处与致命的颅内出血并发症。在这篇综述中，我们总结了原发性和转移性肿瘤颅内出血风险的现有证据和最近的研究，以及治疗性抗凝的影响。我们发现，对于大多数原发性和治疗性转移性脑肿瘤，自发性出血的风险是可以接受的，并且通过使用低分子量肝素或直接口服抗凝剂进行仔细的治疗性抗凝，不会进一步增加出血风险，尽管血小板减少症（血小板计数<50,000/μL）和其他凝血障碍是相对禁忌症。来自黑色素瘤、肾细胞癌、绒毛膜癌、甲状腺癌和肝细胞癌的脑转移瘤患者比其他恶性肿瘤患者更容易自发性出血，因此在考虑治疗性抗凝之前，需要常规进行脑部成像和其他策略，例如在下腔静脉血栓形成的急性情况下放置下腔静脉滤器。
恶性胶质瘤与静脉血栓形成和颅内出血的风险增加有关，但治疗性抗凝相关的额外出血风险似乎是可以接受的，尤其是在治疗原发性肿瘤之后。大多数接受治疗的脑转移瘤患者发生与治疗性抗凝相关的颅内出血的风险较低，低分子量肝素目前是首选药物。未治疗的来自黑色素瘤、肾细胞癌、甲状腺癌、绒毛膜癌和肝细胞癌的脑转移瘤患者自发性颅内出血的倾向较高，在静脉血栓形成的急性情况下，全身抗凝可能是禁忌的。
