A 60 year old male with a known history of metastatic renal cell cancer was transferred to our hospital with an intracerebral hemorrhage. He had known metastatic disease to the brain and developed a DVT. He was started on Lovenox for anticoagulation and proceeded to bleed into one his brain lesions. I thought this posed an interesting question about what is the evidence regarding anticoagulation in the setting of brain mets.
The current recommendation IS to anticoagulate DVTs in the setting of primary brain tumors and metastatic disease that has a low propensity to bleeding.
In order to discern which metastatic diseases have a low propensity to bleed, it is easier to state which have a HIGH propensity to bleed: melanoma, choriocarcinoma, thyroid carcinoma and renal cell carcinoma. If a patient is suffering from brain metastases from one of these conditions and develops a DVT/PE, the recommendation is to not anticoagulate these patients and to place a permanent IVC filter. Some authors have stated that if there is a single brain lesion associated with one of the above cancers and that lesion is resected and the person develops thrombosis then aspirin should be used.
In the above mentioned patient, the literature would not have supported anticoagulation in this patient. In the end, this patient did received a permanent IVC filter. He does have some visual field defects associated with his cerebral hemorrhage.