1
|
Anti-platelet medications and risk of intracranial hemorrhage in patients with metastatic brain tumors. Blood Adv 2022; 6:1559-1565. [PMID: 35086145 PMCID: PMC8905695 DOI: 10.1182/bloodadvances.2021006470] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/18/2022] [Indexed: 11/29/2022] Open
Abstract
Antiplatelet medication was not associated with an increased risk of ICH in patients with metastatic brain tumors. Combined antiplatelet agents and anticoagulation was not associated with an increased risk of ICH compared with single-agent use.
Although intracranial hemorrhage (ICH) is frequent in the setting of brain metastases, there are limited data on the influence of antiplatelet agents on the development of brain tumor–associated ICH. To evaluate whether the administration of antiplatelet agents increases the risk of ICH, we performed a matched cohort analysis of patients with metastatic brain tumors with blinded radiology review. The study population included 392 patients with metastatic brain tumors (134 received antiplatelet agents and 258 acted as controls). Non–small cell lung cancer was the most common malignancy in the cohort (74.0%), followed by small cell lung cancer (9.9%), melanoma (4.6%), and renal cell cancer (4.3%). Among those who received an antiplatelet agent, 86.6% received aspirin alone and 23.1% received therapeutic anticoagulation during the study period. The cumulative incidence of any ICH at 1 year was 19.3% (95% CI, 14.1-24.4) in patients not receiving antiplatelet agents compared with 22.5% (95% CI, 15.2-29.8; P = .22, Gray test) in those receiving antiplatelet agents. The cumulative incidence of major ICH was 5.4% (95% CI, 2.6-8.3) among controls compared with 5.5% (95% CI, 1.5-9.5; P = .80) in those exposed to antiplatelet agents. The combination of anticoagulation plus antiplatelet agents did not increase the risk of major ICH. The use of antiplatelet agents was not associated with an increase in the incidence, size, or severity of ICH in the setting of brain metastases.
Collapse
|
2
|
Ehret F, Kaul D, Mose L, Budach V, Vajkoczy P, Fürweger C, Haidenberger A, Muacevic A, Mehrhof F, Kufeld M. Intracranial Hemorrhage in Patients with Anticoagulant Therapy Undergoing Stereotactic Radiosurgery for Brain Metastases: A Bi-Institutional Analysis. Cancers (Basel) 2022; 14:cancers14030465. [PMID: 35158734 PMCID: PMC8833468 DOI: 10.3390/cancers14030465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/09/2022] [Accepted: 01/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Stereotactic radiosurgery (SRS) is a well-established treatment modality for brain metastases (BM). Given the manifold implications of metastatic cancer on the body, affected patients have an increased risk of comorbidities, such as atrial fibrillation (AF) and venous thromboembolism (VTE), which includes pulmonary embolism (PE) and deep-vein thrombosis (DVT). These may require therapeutic anticoagulant therapy (ACT). Limited data are available on the risk of intracranial hemorrhage (ICH) after SRS for patients with BM who are receiving ACT. This bi-institutional analysis aimed to describe the bleeding risk for this patient subgroup. Methods: Patients with ACT at the time of single-fraction SRS for BM from two institutions were eligible for analysis. The cumulative incidence of ICH with death as a competing event was assessed during follow-up with magnetic resonance imaging or computed tomography. Results: Forty-one patients with 97 BM were included in the analyses. The median follow-up was 8.2 months (range: 1.7–77.5 months). The median and mean BM volumes were 0.47 and 1.19 cubic centimeters, respectively. The most common reasons for ACT were PE (41%), AF (34%), and DVT (7%). The ACT was mostly performed utilizing phenprocoumon (37%), novel oral anticoagulants (32%), or low-molecular-weight heparin (20%). Nine BM from a group of five patients with ICH after SRS were identified: none of them caused neurological or any other deficits. The 6-, 12-, and 18-month cumulative bleeding incidences per metastasis were 2.1%, 12.4%, and 12.4%, respectively. The metastases with previous bleeding events and those originating from malignant melanomas were found to more frequently demonstrate ICH after SRS (p = 0.02, p = 0.01). No surgical or medical intervention was necessary for ICH management, and no observed death was associated with an ICH. Conclusion: Patients receiving an ACT and single-fraction SRS for small- to medium-sized BM did not seem to have a clinically relevant risk of ICH. Previous bleeding and metastases originating from a malignant melanoma may favor bleeding events after SRS. Further studies are needed to validate our reported findings.
Collapse
Affiliation(s)
- Felix Ehret
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.); (F.M.)
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
- Correspondence:
| | - David Kaul
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.); (F.M.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité CyberKnife Center, 13353 Berlin, Germany;
| | - Lucas Mose
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
| | - Volker Budach
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.); (F.M.)
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité CyberKnife Center, 13353 Berlin, Germany;
| | - Peter Vajkoczy
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité CyberKnife Center, 13353 Berlin, Germany;
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurosurgery, 10117 Berlin, Germany
| | - Christoph Fürweger
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
- Department of Stereotaxy and Functional Neurosurgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Alfred Haidenberger
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
| | - Alexander Muacevic
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
| | - Felix Mehrhof
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Radiation Oncology, 13353 Berlin, Germany; (D.K.); (V.B.); (F.M.)
| | - Markus Kufeld
- European Radiosurgery Center, 81377 Munich, Germany; (L.M.); (C.F.); (A.H.); (A.M.); (M.K.)
| |
Collapse
|
3
|
Sasank V, Venkateswarlu S. An automatic tumour growth prediction based segmentation using full resolution convolutional network for brain tumour. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2021.103090] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
4
|
Cai Q, Zhang X, Chen H. Patients with venous thromboembolism after spontaneous intracerebral hemorrhage: a review. Thromb J 2021; 19:93. [PMID: 34838069 PMCID: PMC8626951 DOI: 10.1186/s12959-021-00345-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/14/2021] [Indexed: 01/17/2023] Open
Abstract
Background Patients with spontaneous intracerebral hemorrhage (ICH) have a higher risk of venous thromboembolism (VTE) and in-hospital VTE is independently associated with poor outcomes for this patient population. Methods A comprehensive literature search about patients with VTE after spontaneous ICH was conducted using databases MEDLINE and PubMed. We searched for the following terms and other related terms (in US and UK spelling) to identify relevant studies: intracerebral hemorrhage, ICH, intraparenchymal hemorrhage, IPH, venous thromboembolism, VTE, deep vein thrombosis, DVT, pulmonary embolism, and PE. The search was restricted to human subjects and limited to articles published in English. Abstracts were screened and data from potentially relevant articles was analyzed. Results The prophylaxis and treatment of VTE are of vital importance for patients with spontaneous ICH. Prophylaxis measures can be mainly categorized into mechanical prophylaxis and chemoprophylaxis. Treatment strategies include anticoagulation, vena cava filter, systemic thrombolytic therapy, catheter-based thrombus removal, and surgical embolectomy. We briefly summarized the state of knowledge regarding the prophylaxis measures and treatment strategies of VTE after spontaneous ICH in this review, especially on chemoprophylaxis and anticoagulation therapy. Early mechanical prophylaxis, especially with intermittent pneumatic compression, is recommended by recent guidelines for patients with spontaneous ICH. While decision-making on chemoprophylaxis and anticoagulation therapy evokes debate among clinicians, because of the concern that anticoagulants may increase the risk of recurrent ICH and hematoma expansion. Uncertainty still exists regarding optimal anticoagulants, the timing of initiation, and dosage. Conclusion Based on current evidence, we deem that initiating chemoprophylaxis with UFH/LMWH within 24–48 h of ICH onset could be safe; anticoagulation therapy should depend on individual clinical condition; the role of NOACs in this patient population could be promising.
Collapse
Affiliation(s)
- Qiyan Cai
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Xin Zhang
- Respiratory Disease Department, Xinqiao Hospital, Chongqing, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
| |
Collapse
|
5
|
Winther-Larsen A, Sandfeld-Paulsen B, Hvas AM. New Insights in Coagulation and Fibrinolysis in Patients with Primary Brain Cancer: A Systematic Review. Semin Thromb Hemost 2021; 48:323-337. [PMID: 34624915 DOI: 10.1055/s-0041-1733961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Patients with primary brain tumors have a high incidence of thrombosis and hemorrhage. The underlying mechanism is believed to be derangement of their hemostatic system. To get nearer a clarification of this, we aimed to systematically review the existing literature regarding primary and secondary hemostasis as well as fibrinolysis in patients with primary brain tumor. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The databases PubMed, Embase, and Web of Science were searched on December 15, 2020, without time restrictions. Studies were included if they evaluated at least one blood coagulation and/or fibrinolysis parameter in patients with primary brain cancer. In total, 26 articles including 3,288 patients were included. Overall, increased activity of secondary hemostasis was observed as increased prothrombin fragment 1 + 2 and endogenous thrombin generation levels were found in glioma patients compared with controls. Furthermore, data showed a state of hypofibrinolysis with increased plasminogen activator inhibitor 1 and prolonged clot lysis time in glioma patients. In contrast, no consistent increase in the primary hemostasis was identified; however, data suggested that increased sP-selectin could be a biomarker of increased venous thromboembolism risk and that increased platelet count may be prognostic for survival. Lastly, data indicated that fibrinogen and D-dimer could hold prognostic value. In conclusion, this review indicates that an increased activity of secondary hemostasis and impaired fibrinolysis could be important players in the pathogeneses behind the high risk of thromboembolisms observed in brain cancer patients. Thus, long-term thromboprophylaxis may be beneficial and additional studies addressing this issue are wanted.
Collapse
Affiliation(s)
- Anne Winther-Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | | | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
6
|
Hamed M, Schäfer N, Bode C, Borger V, Potthoff AL, Eichhorn L, Giordano FA, Güresir E, Heimann M, Ko YD, Landsberg J, Lehmann F, Radbruch A, Scharnböck E, Schaub C, Schwab KS, Weller J, Herrlinger U, Vatter H, Schuss P, Schneider M. Preoperative Metastatic Brain Tumor-Associated Intracerebral Hemorrhage Is Associated With Dismal Prognosis. Front Oncol 2021; 11:699860. [PMID: 34595109 PMCID: PMC8476918 DOI: 10.3389/fonc.2021.699860] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
Object Intra-tumoral hemorrhage is considered an imaging characteristic of advanced cancer disease. However, data on the influence of intra-tumoral hemorrhage in patients with brain metastases (BM) remains scarce. We aimed at investigating patients with BM who underwent neurosurgical resection of the metastatic lesion for a potential impact of preoperative hemorrhagic transformation on overall survival (OS). Methods Between 2013 and 2018, 357 patients with BM were surgically treated at the authors’ neuro-oncological center. Preoperative magnetic resonance imaging (MRI) examinations were assessed for the occurrence of malignant hemorrhagic transformation. Results 122 of 375 patients (34%) with BM revealed preoperative intra-tumoral hemorrhage. Patients with hemorrhagic transformed BM exhibited a median OS of 5 months compared to 12 months for patients without intra-tumoral hemorrhage. Multivariate analysis revealed preoperative hemorrhagic transformation as an independent and significant predictor for worsened OS. Conclusions The present study identifies preoperative intra-tumoral hemorrhage as an indicator variable for poor prognosis in patients with BM undergoing neurosurgical treatment.
Collapse
Affiliation(s)
- Motaz Hamed
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Niklas Schäfer
- Division of Clinical Neuro-Oncology, Department of Neurology, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Christian Bode
- Department of Anesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Anna-Laura Potthoff
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Lars Eichhorn
- Department of Anesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Muriel Heimann
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Yon-Dschun Ko
- Department of Oncology and Hematology, Center of Integrated Oncology (CIO) Bonn, Johanniter Hospital Bonn, Bonn, Germany
| | - Jennifer Landsberg
- Department of Dermatology and Allergy, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Felix Lehmann
- Department of Anesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Alexander Radbruch
- Department of Neuroradiology, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Elisa Scharnböck
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Christina Schaub
- Division of Clinical Neuro-Oncology, Department of Neurology, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Katjana S Schwab
- Department of Internal Medicine III, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Johannes Weller
- Division of Clinical Neuro-Oncology, Department of Neurology, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Ulrich Herrlinger
- Division of Clinical Neuro-Oncology, Department of Neurology, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Patrick Schuss
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| | - Matthias Schneider
- Department of Neurosurgery, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany
| |
Collapse
|
7
|
Gerotziafas GT, Mahé I, Lefkou E, AboElnazar E, Abdel-Razeq H, Taher A, Antic D, Elalamy I, Syrigos K, Van Dreden P. Overview of risk assessment models for venous thromboembolism in ambulatory patients with cancer. Thromb Res 2021; 191 Suppl 1:S50-S57. [PMID: 32736779 DOI: 10.1016/s0049-3848(20)30397-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/15/2020] [Accepted: 01/23/2020] [Indexed: 02/07/2023]
Abstract
A B S T R A C T Important progress has been made in the development of risk assessment models (RAM) for the identification of outpatients on anticancer treatment at risk of venous thromboembolism (VTE). Since the breakthrough publication of the original Khorana risk score (KRS) more than 10 years ago, a new generation of KRS-based scores have been developed, including the Vienna Cancer and Thrombosis Study, PROTECHT, CONKO, ONCOTEV, TicOnco and the CATS/MICA score. Among these the CATS/MICA score showed that a simplified score composed of only two calibrated predictors, the type of cancer and the D-dimer levels, offers a user-friendly tool for the evaluation of cancer-associated thrombosis (CAT) risk. The COMPASS-CAT score is the first that introduced a more synthetic approach of risk evaluation by combining cancer-related predictors with patient comorbidity in a score which is designed for the types of cancer frequently seen in the community (i.e. breast, lung colon or ovarian cancers) and has been externally validated in independent studies. The Throly score is registered as part of the same group as it has a similar structure to the COMPASS-CAT score and is applicable in patients with lymphoma. The incorporation of specific biomarkers of hypercoagulability to the RAM for CAT offers the possibility to perform a precision medicine approach in the prevention of CAT. The improvement of RAM for CAT with artificial intelligence methodologies and deep learning techniques is the challenge in the near future.
Collapse
Affiliation(s)
- Grigoris T Gerotziafas
- Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France; Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Paris, France; Department of Hematology and Cell Therapy, Saint Antoine Hospital, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France.
| | - Isabelle Mahé
- Internal Medicine Department, Hôpital Louis Mourier, APHP, Colombes, Inserm UMR_S1140, Université Paris-Diderot Paris7, Paris, France
| | - Eleftheria Lefkou
- Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France
| | | | - Hiqmat Abdel-Razeq
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Ali Taher
- Department of Internal Medicine, Division of Hematology/Oncology, American University of Beirut, Lebanon
| | - Darko Antic
- Clinic for Hematology, Clinical Center Serbia, University of Belgrade, Belgrade, Serbia
| | - Ismail Elalamy
- Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France; Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Kostas Syrigos
- Oncology Unit, 3(rd) Dept of Medicine, National and Kapodistrian University of Athens, School of Medicine, "Sotiria" General Hospital, Athens, Greece
| | - Patrick Van Dreden
- Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France; Clinical Research Department, Diagnostica Stago, Gennevilliers, France
| |
Collapse
|
8
|
Zoccarato M, Nardetto L, Basile AM, Giometto B, Zagonel V, Lombardi G. Seizures, Edema, Thrombosis, and Hemorrhages: An Update Review on the Medical Management of Gliomas. Front Oncol 2021; 11:617966. [PMID: 33828976 PMCID: PMC8019972 DOI: 10.3389/fonc.2021.617966] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/04/2021] [Indexed: 12/21/2022] Open
Abstract
Patients affected with gliomas develop a complex set of clinical manifestations that deeply impact on quality of life and overall survival. Brain tumor-related epilepsy is frequently the first manifestation of gliomas or may occur during the course of disease; the underlying mechanisms have not been fully explained and depend on both patient and tumor factors. Novel treatment options derive from the growing use of third-generation antiepileptic drugs. Vasogenic edema and elevated intracranial pressure cause a considerable burden of symptoms, especially in high-grade glioma, requiring an adequate use of corticosteroids. Patients with gliomas present with an elevated risk of tumor-associated venous thromboembolism whose prophylaxis and treatment are challenging, considering also the availability of new oral anticoagulant drugs. Moreover, intracerebral hemorrhages can complicate the course of the illness both due to tumor-specific characteristics, patient comorbidities, and side effects of antithrombotic and antitumoral therapies. This paper aims to review recent advances in these clinical issues, discussing the medical management of gliomas through an updated literature review.
Collapse
Affiliation(s)
- Marco Zoccarato
- Neurology Unit, O.S.A., Azienda Ospedale-Università, Padua, Italy
| | - Lucia Nardetto
- Neurology Unit, O.S.A., Azienda Ospedale-Università, Padua, Italy
| | | | - Bruno Giometto
- Neurology Unit, Trento Hospital, Azienda Provinciale per i Servizi Sanitari (APSS) di Trento, Trento, Italy
| | - Vittorina Zagonel
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCSS, Padua, Italy
| | - Giuseppe Lombardi
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV-IRCSS, Padua, Italy
| |
Collapse
|
9
|
Acute treatment of venous thromboembolism. Blood 2020; 135:305-316. [PMID: 31917399 DOI: 10.1182/blood.2019001881] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022] Open
Abstract
All patients with venous thromboembolism (VTE) should receive anticoagulant treatment in the absence of absolute contraindications. Initial anticoagulant treatment is crucial for reducing mortality, preventing early recurrences, and improving long-term outcome. Treatment and patient disposition should be tailored to the severity of clinical presentation, to comorbidities, and to the potential to receive appropriate care in the outpatient setting. Direct oral anticoagulants (DOACs) used in fixed doses without laboratory monitoring are the agents of choice for the treatment of acute VTE in the majority of patients. In comparison with conventional anticoagulation (parenteral anticoagulants followed by vitamin K antagonists), these agents showed improved safety (relative risk [RR] of major bleeding, 0.61; 95% confidence interval [CI], 0.45-0.83) with a similar risk of recurrence (RR, 0.90; 95% CI, 0.77-1.06). Vitamin K antagonists or low molecular weight heparins are still alternatives to DOACs for the treatment of VTE in specific patient categories such as those with severe renal failure or antiphospholipid syndrome, or cancer, respectively. In addition to therapeutic anticoagulation, probably less than 10% of patients require reperfusion by thrombolysis or interventional treatments; those patients are hemodynamically unstable with acute pulmonary embolism, and a minority of them have proximal limb-threatening deep vein thrombosis (DVT). The choice of treatment should be driven by the combination of evidence from clinical trials and by local expertise. The majority of patients with acute DVT and a proportion of selected hemodynamically stable patients with acute pulmonary embolism can be safely managed as outpatients.
Collapse
|