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A review of anticoagulation in patients with central nervous system malignancy: between a rock and a hard place

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Abstract

The incidence and prevalence of patients who develop primary and secondary metastatic central nervous system cancer (CNS) is increasing. This is a consequence of advancements in the sensitivity and availability of diagnostic imaging, and improved therapeutic options, leading to increased detection of CNS malignancies and improved survival. These patients are at very high risk of thrombosis as well as haemorrhage, and the optimum management of anticoagulation can be challenging for treating clinicians, particularly as robust prospective evidence is sparse. In this focused review, we discuss (1) risk factors for thrombosis and bleeding in these patients, (2) management of acute venous thromboembolism (VTE) including evidence for direct oral anticoagulants, and how to approach patients with contraindications to anticoagulation, (3) ambulatory VTE prophylaxis, (4) VTE prophylaxis in patients who have undergone craniotomy for cancer, and (5) management of anticoagulation-related intracranial haemorrhage. Based on review of the available literature and author opinion, we propose practical management algorithms to aid clinicians faced with treating CNS cancer patients with thrombosis or CNS haemorrhage.

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Authors and Affiliations

  1. Department of Haematology, University Hospital Galway, Galway, Republic of Ireland

    Dawn Swan

  2. Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    David Julian Seiffge

  3. Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK

    Jecko Thachil

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  1. Dawn Swan
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  2. David Julian Seiffge
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Correspondence to Dawn Swan.

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JT: honoraria from BMS-Pfizer, Boehringer, Bayer and Daichii-Sankyo. DJS: scientific advisory boards for Bayer and Pfizer, compensation for educational efforts from Stago, research funding from Portola, and Speaker bureau: NOAC education, Portola.

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Swan, D., Seiffge, D.J. & Thachil, J. A review of anticoagulation in patients with central nervous system malignancy: between a rock and a hard place. J Neurol 268, 2390–2401 (2021). https://doi.org/10.1007/s00415-020-09775-7

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