Management of venous thromboembolism (VTE) in hemodynamically stable adults with brain tumors

CrCl: creatinine clearance; CT: computed tomography; DOAC: direct oral anticoagulant; ICH: intracranial hemorrhage; IV: intravenous; IVC: inferior vena cava; LMWH: low molecular weight heparin; MRI: magnetic resonance imaging.

* Interpretation of noncontrast head CT in patients with brain tumors can be challenging and often requires comparison with prior MRIs and CTs. For patients with equivocal findings on CT, brain MRI may help distinguish new versus old blood products and tumor-related calcifications.

¶ In all patients, the decision to anticoagulate should be individualized and the benefits of VTE prevention carefully weighed against the risk of bleeding. Specific considerations in patients with brain tumors include brain tumor type and grade, history of and risk for intratumoral hemorrhage, and concomitant therapies (eg, antiangiogenic agents). Refer to UpToDate topic review for further discussion of absolute and relative contraindications to anticoagulation in patients with brain tumors.

Δ Examples include baseline blood products on head CT or prior intratumoral hemorrhage in the face of high clot burden/massive pulmonary embolism.

◊ The goal of IVC filter placement is prevention of thrombus embolization to the lung. Infrarenal IVC filter placement has no prophylactic value in patients with upper extremity thrombus. Retrievable filters are always preferred.

§ For dosing considerations and selection of a specific agent, refer to UpToDate topic reviews on initial and subsequent anticoagulation for the treatment of VTE.

¥ Extended or lifelong therapy is suggested in most patients with glioblastoma and other forms of active cancer. Decisions about longer-term anticoagulation in patients with benign or low-grade brain tumors and those with an elevated bleeding risk should be individualized.

‡ For select patients it may be reasonable to begin DOAC therapy at the maintenance dose instead of the acute phase dose, based on an assessment of risk of intracranial hemorrhage versus the need for urgent anticoagulation.