Intracranial hemorrhage in cancer patients treated with anticoagulation

• Intracranial hemorrhage occurs in upwards of 20% patients with brain metastasis
• Therapeutic anticoagulation does not appear to increase the risk of intracranial hemorrhage in the setting of either primary or metastatic brain tumors
• Tumors with high expression of VEGF such as renal cell carcinoma, melanoma, and glioblastoma are associated with the highest risk of intracranial hemorrhage
• The size and location of intracranial hemorrhage are principal determinants in the acute management (i.e. surgical or medical) of intracranial hemorrhage

ABSTRACTBoth venous thromboembolism and intracranial metastases are common complications in the setting of primary brain tumors and metastatic malignancies. Anticoagulation is indicated in the presence of cancer-associated thrombosis in order to limit the risk of pulmonary embolism; however, there is reluctance to initiate anticoagulation in the setting of intracranial metastatic disease due to potential for intracranial hemorrhage. Recent evidence suggests that therapeutic anticoagulation can be safely administered in the setting of metastatic brain tumors. This review examines the current understanding of the pathophysiology of intracranial hemorrhage in malignancy, describes the incidence of intracranial hemorrhage in the setting of brain tumors with therapeutic anticoagulation, and outlines management strategies relevant to the treatment of intracranial hemorrhage in the setting of anticoagulation.