Anticoagulation for the treatment of venous thromboembolism in patients with brain metastases: a meta-analysis and systematic review

The risk benefit decision in providing anticoagulation for patients with brain metastases is amongst the most difficult decisions faced by clinicians. The purpose of our study was to evaluate both the risk of intracerebral hemorrhage (ICH) associated with anticoagulation therapy and the effect of anticoagulation on survival in patients with brain metastases and venous thromboembolism (VTE). A systematic review of the literature was performed via the PubMed, EMBASE, and the Cochrane databases. Our initial search resulted in 1304 unique citations, and 5 studies satisfied all eligibility criteria and were included for analysis. The odds ratio for development of ICH in the setting of anticoagulation was 1.37 (CI 0.86–2.17, p = 0.18). The hazard ratio for survival was 0.96 (CI 0.51–1.81, p = 0.90). While limited, the best available evidence suggests that there is no increased risk of ICH and no survival benefit associated with providing anticoagulation to patients with brain metastases who develop VTE. These patients merit individualized discussion of the risk and benefit of anticoagulation therapy. Current guidelines should be updated to include more recent studies and highlight the uncertainty of the net clinical benefit associated with anticoagulation.