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The management of thromboembolic disease in patients with central nervous system malignancies

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Opinion statement

Venous thromboembolic disease (VTE) is a common complication of malignancies affecting the central nervous system (CNS), both in the perioperative period and throughout the disease course. Until recently, the perceived risk of intracranial hemorrhage in patients with CNS malignancies was felt to be a relative contraindication to systemic anticoagulation, and most patients were managed with nonpharmacologic methods in both the prophylactic and treatment setting. However, several studies of the safety and efficacy of anticoagulation in both neurosurgical and cancer patients have challenged the previous dogma, and routine use of unfractionated heparin or low molecular weight heparin (LMWH) for VTE prophylaxis in patients undergoing craniotomy for CNS malignancy is recommended. Likewise, treatment of established VTE in this population with heparins is recommended, at least initially, followed by long-term treatment either with heparin or oral warfarin. Complications of inferior vena cava (IVC) filters, used as an alternative to systemic anticoagulation, appear to be more common in brain tumor patients with VTE, lending further support to treatment with systemic anticoagulation when possible. We advocate a multimodality approach utilizing compression stockings, intermittent compression devices, and heparin in the perioperative setting as the best proven method to reduce the risk of VTE. In the absence of a strict contraindication to systemic anticoagulation, such as previous intracranial hemorrhage or profound thrombocytopenia, LMWH is recommended in brain tumor patients with newly diagnosed VTE, followed by long-term warfarin or LMWH.

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References and Recommended Reading

  1. Levi AD, Wallace MC, Bernstein M, Walters BC: Venous thromboembolism after brain tumor surgery: a retrospective review. Neurosurgery 1991, 28:859–863.

    Article  PubMed  CAS  Google Scholar 

  2. Sawaya R, Zuccarello M, Elkalliny M, Nishiyama H: Postoperative venous thromboembolism and brain tumors: part I. J Neurooncol 1992, 14:119–125.

    PubMed  CAS  Google Scholar 

  3. Brandes A, Scelzi E, Salmistraro G, et al.: Incidence of risk of thromboembolism during treatment highgrade gliomas: a prospective study. Eur J Cancer 1997, 33:1592–1596.

    Article  PubMed  CAS  Google Scholar 

  4. Streiff MB, Segal J, Grossman SA, Kickler et al.: ABO blood group is a potent risk factor for venous thromboembolism in patients with malignant gliomas. Cancer 2004, 100:1717–1723.

    Article  PubMed  Google Scholar 

  5. Walsh DC, and Kakkar AK: Thromboembolism in brain tumors. Curr Opin Pulm Med 2001, 7:326–331. Excellent review of the molecular interactions between brain tumors and the hemostatic system and the evidence to support the use of the LMWHs in the prevention and treatment of VTE.

    Article  PubMed  CAS  Google Scholar 

  6. Thoron L, and Arbit E: Hemostatic changes in patients with brain tumors. J Neurooncol 1994, 22:87–100.

    Article  PubMed  CAS  Google Scholar 

  7. Sawaya RE and Ligon BL: Thromboembolic complications associated with brain tumors. J Neurooncol 1994, 22:173–181.

    Article  PubMed  CAS  Google Scholar 

  8. Sawaya R and Glas-Greenwalt P: Postoperative venous thromboembolism and brain tumors: part II. hemostatic profile. J Neurooncol 1992, 14:127–134.

    PubMed  CAS  Google Scholar 

  9. Landau BJ, Kwaan HC, Verrusio EN, and Brem SS: Elevated levels of urokinase-type plasminogen activator and plasminogen activator inhibitor type-1 in malignant human brain tumors. Cancer Res 1994, 54:1105–1108.

    PubMed  CAS  Google Scholar 

  10. Sawaya R and Highsmith RF: Postoperative venous thromboembolism and brain tumors: part III. J Neurooncol 1992, 14:113–118.

    PubMed  CAS  Google Scholar 

  11. Vukovich TC, Gabriel A, Schaeffer B, et al.: Hemostasis activation in patients undergoing brain tumor surgery. J Neurosurg 1997, 87:508–511.

    PubMed  CAS  Google Scholar 

  12. Sonaglia F, Agnelli G, Baroni M, et al.: Pre-operative plasma levels of soluble fibrin polymers correlate with the development of deep vein thrombosis after elective neurosurgery. Blood Coagul Fibrinolysis 1999, 10:459–463.

    PubMed  CAS  Google Scholar 

  13. Iberti TJ, Miller M, Abalos A, et al.: Abnormal coagulation profile in brain tumor patients during surgery. Neurosurgery 1994, 34:389–394.

    Article  PubMed  CAS  Google Scholar 

  14. Cheruku R, Tapazoglou E, Ensley J, et al.: The incidence and significance of thromboembolic complications in patients with high-grade gliomas. Cancer 1991, 68:2621–2624.

    Article  PubMed  CAS  Google Scholar 

  15. Hamilton MG, Hull RD, and Pineo GF: Venous thromboembolism in neurosurgery and neurology patients: a review. Neurosurgery 1994, 34:280–296.

    Article  PubMed  CAS  Google Scholar 

  16. Rodas RA, Fenstermaker RA, McKeever PE, et al.: Correlation of intraluminal thrombosis in brain tumor vessels with postoperative thrombotic complications: a preliminary report. J Neurosurg 1998, 89:200–205.

    Article  PubMed  CAS  Google Scholar 

  17. Sciacca FL, Ciusani E, Silvani A, et al.: Genetic and plasma markers of venous thromboembolism in patients with high grade glioma. Clin Cancer Res 2004, 10:1312–1317.

    Article  PubMed  CAS  Google Scholar 

  18. Iorio A, Agnelli G: Low-molecular-weight and unfractionated heparin for prevention of venous thromboembolism in neurosurgery: a meta-analysis. Arch Intern Med 2000, 60:2327–2332.

    Article  Google Scholar 

  19. Dickinson LD, Miller LD, Patel CP, Gupta SK: Enoxaparin increases the incidence of postoperative intracranial hemorrhage when initiated preoperatively for deep venous thrombosis prophylaxis in patients with brain tumors. Neurosurgery 1998, 43:1074–1081.

    Article  PubMed  CAS  Google Scholar 

  20. Cerrato D, Ariano C, Fiacchino F: Deep vein thrombosis and low-dose heparin prophylaxis in neurosurgical patients. J Neurosurg 1978, 49:378–381.

    Article  PubMed  CAS  Google Scholar 

  21. Raabe A, Gerlach R, Zimmermann M, Seifert V: The risk of haemorrhage associated with early postoperative heparin administration after intracranial surgery. Acta Neurochir (Wien) 2001, 143:1–7.

    Article  CAS  Google Scholar 

  22. Macdonald RL, Amidei C, Lin G, et al.: Safety of perioperative subcutaneous heparin for prophylaxis of venous thromboembolism in patients undergoing craniotomy. Neurosurgery 1999, 45:245–251.

    Article  PubMed  CAS  Google Scholar 

  23. Goldhaber SZ, Dunn K, Gerhard-Herman M, et al.: Low rate of venous thromboembolism after craniotomy for brain tumor using multimodality prophylaxis. Chest 2002, 122:1933–1937.

    Article  PubMed  Google Scholar 

  24. Hart, RG: Rose, BD, ed: Anticoagulant and Antiplatelet Therapy in Patients with Brain Tumor. Massachusets: Wellesley; 2004.

    Google Scholar 

  25. Wen PY, Bachoo R, Rose, BD, ed: Medical Management of Patients with Brain Tumors. Massachusets: Wellesley; 2004.

    Google Scholar 

  26. Quevedo JF, Buckner JC, Schmidt JL, et al.: Thromboembolism in patients with high-grade glioma. Mayo Clin Proc 1994, 69:329–332.

    PubMed  CAS  Google Scholar 

  27. Altschuler E, Moosa H, Selker RG, Vertosick FT Jr: The risk and efficacy of anticoagulant therapy in the treatment of thromboembolic complications in patients with primary malignant brain tumors. Neurosurgery 1990, 27:74–76.

    Article  PubMed  CAS  Google Scholar 

  28. Ruff RL and Posner JB: Incidence and treatment of peripheral venous thrombosis in patients with glioma. Ann Neurol 1983, 13:334–336.

    Article  PubMed  CAS  Google Scholar 

  29. Deveras R, Kaldate R, Kessler CM: Observational study of deep vein thrombosis management in patients with central nervous system malignancy [abstract]. Blood 2003, 11:102.

    Google Scholar 

  30. Agnelli G, Piovella F, Buoncristiani P, et al.: Enoxaparin plus compression stockings compared with compression stockings alone in the prevention of venous thromboembolism after elective neurosurgery. N Engl J Med 1998, 339:80–85.

    Article  PubMed  CAS  Google Scholar 

  31. Lee AY, Levine MN, Baker RI, et al.: Low-molecularweight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 2003, 349:146–153.

    Article  PubMed  CAS  Google Scholar 

  32. Kearon C, Ginsberg JS, Kovacs MJ, et al.: Comparison of low-intensity warfarin therapy with conventionalintensity warfarin therapy for long-term prevention of recurrent venous thromboembolism. N Engl J Med 2003, 349:631–639.

    Article  PubMed  CAS  Google Scholar 

  33. Ridker PM, Goldhaber SZ, Danielson E, et al.: Longterm, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism. N Engl J Med 2003, 348:1425–1434.

    Article  PubMed  CAS  Google Scholar 

  34. Levin JM, Schiff D, Loeffler JS, et al.: Complications of therapy for venous thromboembolic disease in patients with brain tumors. Neurology 1993, 43:1111–1114.

    PubMed  CAS  Google Scholar 

  35. Schiff D and DeAngelis LM: Therapy of venous thromboembolism in patients with brain metastases. Cancer 1994, 73:493–498.

    Article  PubMed  CAS  Google Scholar 

  36. Olin JW, Young JR, Graor RA, et al.: Treatment of deep vein thrombosis and pulmonary emboli in patients with primary and metastatic brain tumors. Anticoagulants or inferior vena cava filter? Arch Intern Med 1987, 147:2177–2179. Addresses management of the most common medical problems in brain tumor patients.

    Article  PubMed  CAS  Google Scholar 

  37. Wen PY and Marks PW: Medical management of patients with brain tumors. Curr Opin Oncol 2002, 14:299–307.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Section on Hematology and Oncology, Wake Forest University School of Medicine, Medical Center Boulevard, 27157, Winston-Salem, NC, USA

    Mary Ann Knovich MD

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  1. Mary Ann Knovich MD
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  2. Glenn J. Lesser MD
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Knovich, M.A., Lesser, G.J. The management of thromboembolic disease in patients with central nervous system malignancies. Curr. Treat. Options in Oncol. 5, 511–517 (2004). https://doi.org/10.1007/s11864-004-0039-x

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