Therapy of venous thromboembolism in patients with brain metastases

BACKGROUND: Deep venous thrombosis (DVT) and pulmonary embolism (PE) are common in patients with brain metastases. Few data exist to help guide the clinician's choice between the two therapeutic options of anticoagulation and inferior vena cava filter placement. METHODS: The authors reviewed their institutions' experience with the treatment of venous thromboembolism in 51 adult patients with known brain metastases since 1980. RESULTS: Ten patients were initially treated with Greenfield filters; four (40%) had recurrent nonfatal thromboembolic events (two PE and two DVT), and three required anticoagulation. Thirty-nine patients were treated initially with anticoagulation; none of these patients later received filters. Two patients with DVT were untreated and both died of PE. Among 42 patients who received anticoagulation, the duration of anticoagulation ranged from 5 to 563 days (mean, 100 days). Two patients who received anticoagulation experienced devastating central nervous system hemorrhage in the setting of supratherapeutic anticoagulation by conventional laboratory criteria. A third patient experienced a minor deterioration, possibly attributable to hemorrhage, for a 7% (3 of 42) incidence of serious central nervous system complications. Three asymptomatic patients developed hyperdensity within metastases on routine follow-up noncontrast computed tomography scan, suggesting possible intratumoral hemorrhage. Three patients taking warfarin had recurrent DVT with prothrombin time between 15.1 and 17.7. Systemic bleeding complications were generally minor and occurred in only eight patients (19%). CONCLUSIONS: Anticoagulation is more effective than Greenfield filters and acceptably safe when maintained in the therapeutic range in most patients with brain metastases and venous thromboembolism.