Anti-platelet medications and risk of intracranial hemorrhage in patients with metastatic brain tumors

Management of anticoagulation in patients with brain metastasis

Venous thromboembolism (VTE) is a prevalent and serious complication among cancer patients, necessitating therapeutic anticoagulation for many individuals with brain metastases. Simultaneously, patients with brain metastases, particularly those with high-risk primary tumors, have an increased risk of intracranial hemorrhage (ICH). Managing anticoagulation in these patients presents a dual challenge: preventing thromboembolism while avoiding hemorrhagic events. Here, we present our approach to anticoagulation for acute VTE in patients with brain metastases, based on the available evidence. We review potential risk factors for anticoagulation-associated ICH in this population and discuss strategies for managing acute VTE in patients with and without ICH.

Clinical and imaging manifestations of intracerebral hemorrhage in brain tumors and metastatic lesions: a comprehensive overview

PURPOSE

This observational study aims to provide a detailed clinical and imaging characterization/workup of acute intracerebral hemorrhage (ICH) due to either an underlying metastasis (mICH) or brain tumor (tICH) lesion.

METHODS

We conducted a retrospective, single-center study, evaluating patients presenting with occult ICH on initial CT imaging, classified as tICH or mICH on follow-up MRI imaging according to the H-Atomic classification. Demographic, clinical and radiological data were reviewed.

RESULTS

We included 116 patients (tICH: 20/116, 17.24%; mICH: 96/116, 82.76%). The most common malignancies causing ICH were lung cancer (27.59%), malignant melanoma (18.10%) and glioblastoma (10.34%). The three most common stroke-like symptoms observed were focal deficit (62/116, 53.45%), dizziness (42/116, 36.21%) and cognitive impairment (27/116, 23.28%). Highest mICH prevalence was seen in the occipital lobe (mICH: 28.13%, tICH: 0.00%; p = 0.004) with tICH more in the corpus callosum (tICH: 10.00%, mICH: 0.00%; p = 0.029). Anticoagulation therapy was only frequent in mICH patients (tICH: 0.00%, mICH: 5.21%; p = 0.586). Hemorrhage (tICH: 12682 mm3, mICH: 5708 mm3, p = 0.020) and edema volumes (tICH: 49389 mm3, mICH: 20972 mm3, p = 0.035) were significantly larger within tICH patients.

CONCLUSION

More than half of the patients with neoplastic ICH exhibited stroke-like symptoms. Lung cancer was most common in mICH, glioblastoma in tICH. While clinical presentations were similar, significant differences in tumor location and treatments were discernible.

Postoperative Hemorrhage and Venous Thromboembolism in Patients with Pituitary Adenomas Under Acetylsalicylic Acid

Background/Objectives: Postoperative hemorrhages (POHs) after pituitary adenoma surgery can have devastating consequences for patients. Many patients take acetylsalicylic acid (ASA) for the primary or secondary prevention of cardiovascular or stroke events. However, the impact of continued low-dose ASA use on the risk of postoperative hemorrhage and the frequency of thromboembolic events after discontinuing ASA in these patients remain poorly understood. This study aims to investigate the potential interaction and correlation between low-dose ASA intake and two of the most common complications after neurosurgical surgery-acute postoperative hemorrhage and thromboembolism. Methods: A retrospective study involving 1862 patients who underwent brain tumor surgery over a decade at our neurosurgical institute examined the risk of postoperative hemorrhage and thromboembolic events. The study compared bleeding rates in patients with pituitary adenomas who received low-dose ASA medication to those who did not. Additionally, the study investigated the occurrence of venous thromboembolism (VTE) or arterial pulmonary embolisms (PEs) following surgery, as well as the impact of laboratory parameters, demographic characteristics and intraoperative factors. Results: A total of 108 patients underwent surgery for primary pituitary tumors between January 2008 and January 2018. Only six patients (5.6%) experienced POH. Among those with POH, just two (1.9%) required revision surgery due to neurological decline. Interestingly, none of the 13 patients (12%) taking ASA preoperatively suffered POH. No correlation was found between laboratory results, demographics and postoperative complications. The study also did not find an increase in VTE or PE events. Conclusions: In this analysis, the perioperative intake of low-dose ASA could not be associated with an increased rate of hemorrhagic complications following pituitary adenoma surgery. Low-dose ASA can be safely continued during brain tumor surgery in patients with a high cardiovascular and cerebrovascular risk.

How I treat acute venous thromboembolism in patients with brain tumors

ABSTRACT

Venous thromboembolism (VTE) is a common complication in patients with brain tumors. The management of acute VTE is particularly challenging due to an elevated risk of intracranial hemorrhage (ICH). Risk of developing ICH on anticoagulation is influenced by a number of factors including tumor type, recent surgery, concomitant medications, platelet counts, and radiographic features. In patients with a heightened risk for ICH, the benefits of anticoagulation need to be balanced against a likelihood of developing major hemorrhagic complications. Management decisions include whether to administer anticoagulation, at what dose, placement of an inferior vena cava filter, monitoring for development of hemorrhage or progressive thrombus, and escalation of anticoagulant dose. This article discusses the complexities of treating acute VTE in patients with brain tumors and outlines treatment algorithms based on the presence or absence of ICH at the time of VTE diagnosis. Through case-based scenarios, we illustrate our approach to anticoagulation, emphasizing individualized risk assessments and evidence-based practices to optimize treatment outcomes while minimizing the risks of hemorrhagic events in patients with brain tumors.

An MRI radiomics approach to discriminate haemorrhage-prone intracranial tumours before stereotactic biopsy

PURPOSE

To explore imaging biomarkers predictive of intratumoral haemorrhage for lesions intended for elective stereotactic biopsy.

METHOD

This study included a retrospective cohort of 143 patients with 175 intracranial lesions intended for stereotactic biopsy. All the lesions were randomly split into a training dataset ( n =121) and a test dataset ( n =54) at a ratio of 7:3. Thirty-four lesions were defined as "hemorrhage-prone tumors" as haemorrhage occurred between initial diagnostic MRI acquisition and the scheduled biopsy procedure. Radiomics features were extracted from the contrast-enhanced T1 Weighted Imaging and T2 Weighted Imaging images. Features informative of haemorrhage were then selected by the LASSO algorithm, and an Support Vector Machine model was built with selected features. The Support Vector Machine model was further simplified by discarding features with low importance and calculating them using a "permutation importance" method. The model's performance was evaluated with confusion matrix-derived metrics and area under curve (AUC) values on the independent test dataset.

RESULTS

Nine radiomics features were selected as haemorrhage-related features of intracranial tumours by the LASSO algorithm. The simplified model's sensitivity, specificity, accuracy, and AUC reached 0.909, 0.930, 0.926, and 0.949 (95% CI: 0.865-1.000) on the test dataset in the discrimination of "hemorrhage-prone tumors". The permutation method rated feature "T2_gradient_firstorder_10Percentile" as the most important, the absence of which decreased the model's accuracy by 10.9%.

CONCLUSION

Radiomics features extracted on contrast-enhanced T1 Weighted Imaging and T2 Weighted Imaging sequences were predictive of future haemorrhage of intracranial tumours with favourable accuracy. This model may assist in the arrangement of biopsy procedures and the selection of target lesions in patients with multiple lesions.

Cancer and Cardiovascular Disease: The Conjoined Twins

Cancer and cardiovascular disease are the two most common causes of death worldwide. As the fields of cardiovascular medicine and oncology continue to expand, the area of overlap is becoming more prominent demanding dedicated attention and individualized patient care. We have come to realize that both fields are inextricably intertwined in several aspects, so much so that the mere presence of one, with its resultant downstream implications, has an impact on the other. Nonetheless, cardiovascular disease and cancer are generally approached independently. The focus that is granted to the predominant pathological entity (either cardiovascular disease or cancer), does not allow for optimal medical care for the other. As a result, ample opportunities for improvement in overall health care are being overlooked. Herein, we hope to shed light on the interconnected relationship between cardiovascular disease and cancer and uncover some of the unintentionally neglected intricacies of common cardiovascular therapeutics from an oncologic standpoint.

Antiplatelet medications and intracranial hemorrhage in patients with primary brain tumors

BACKGROUND

Spontaneous intracranial hemorrhage (ICH) is a frequent and severe consequence of primary brain tumors. The safety of antiplatelet medications in this patient population is undefined.

OBJECTIVE

The primary objective was to determine whether antiplatelet medications are associated with an increased risk of ICH in patients with primary brain tumors.

PATIENTS/METHODS

We performed a matched, retrospective cohort study of patients with the diagnosis of primary brain tumor treated at our institution between 2010 and 2021. Radiographic images of all potential ICH events underwent blinded review. The primary end point of the study was the cumulative incidence of ICH at 1 year after tumor diagnosis.

RESULTS AND CONCLUSIONS

A total of 387 patients with primary brain tumors were included in the study population (130 exposed to antiplatelet agents, 257 not exposed). The most common malignancy was glioblastoma (n = 256, 66.1%). Among the intervention cohort, 119 patients received aspirin monotherapy. The cumulative incidence of any ICH at 1 year was 11.0% (95% CI, 5.3-16.6) in those receiving antiplatelet medications and 13.0% (95% CI, 8.5-17.6) in those not receiving antiplatelet medications (Gray test, p = 0.6). The cumulative incidence of major ICH was similar between the cohorts (3.3% in antiplatelet cohort vs 2.9% in control cohort, p = 1.0). This study did not identify an increased incidence of ICH in patients with primary brain tumors exposed to antiplatelet medications.