Venous thromboembolism in high-grade glioma
Therapeutic anticoagulation is associated with a 7-fold increase risk of ICH in glioma patients. Data emerging from a study support the need for high-quality studies to evaluate the risk of ICH in patients with glioma and VTE 1).
Venous thromboembolism (VTE) is a common complication in patients with high-grade gliomas, occurring in approximately 24-30% of such patients 2) 3) 4) 5).
In a study of Senders et al. from Boston and Utrecht, patients were extracted from the National Surgical Quality Improvement Program registry (2005-2015) and analyzed using multivariable logistic regression.
A total of 7376 patients were identified, of which 948 (12.9%) experienced a major complication. The most common major complications were reoperation (5.1%), venous thromboembolism (3.5%), and death (2.6%). Furthermore, 15.6% stayed longer than 10 d, and 11.5% were readmitted within 30 d after surgery. The most common reasons for reoperation and readmission were intracranial hemorrhage (18.5%) and wound-related complications (11.9%), respectively. Multivariable analysis identified older age, higher body mass index, higher American Society of Anesthesiologists (ASA) classification, dependent functional status, elevated preoperative white blood cell count (white blood cell count WBC, >12 000 cells/mm3), and longer operative time as predictors of major complication (all P < .001). Higher ASA classification, dependent functional status, elevated WBC, and ventilator dependence were predictors of extended length of stay (all P < .001). Higher ASA classification and elevated WBC were predictors of reoperation (both P < .001). Higher ASA classification and dependent functional status were predictors of readmission (both P < .001). Older age, higher ASA classification, and dependent functional status were predictors of death (all P < .001).
This study provides a descriptive analysis and identifies predictors for short-term complications, including death, after craniotomy for primary malignant brain tumors 6).
Venous thromboembolism in glioblastoma
Case series
To determine the rate of ICH in patients treated with enoxaparin, we performed a matched, retrospective cohort study with blinded radiology review for 133 patients with high-grade glioma. After diagnosis of glioma, the cohort that received enoxaparin was 3 times more likely to develop a major ICH than those not treated with anticoagulation (14.7% vs 2.5%; P = .036; hazard ratio [HR], 3.37; 95% confidence interval [CI], 1.02-11.14). When enoxaparin was analyzed as a time-varying covariate, anticoagulation was associated with a >13-fold increased risk of hemorrhage (HR, 13.26; 95% CI, 3.33-52.85; P < .0001). Overall survival was significantly shorter for patients who suffered a major ICH on enoxaparin compared with patients not receiving anticoagulation (3.3 vs 10.2 months; log-rank P = .012). We applied a validated ICH prediction risk score PANWARDS (platelets, albumin, no congestive heart failure, warfarin, age, race, diastolic blood pressure, stroke), and observed that all major ICHs on enoxaparin occurred in the setting of a PANWARDS score ≥25, corresponding with a sensitivity of 100% (95% CI, 63% to 100%) and a specificity of 40% (95% CI, 25% to 56%). We conclude that caution is warranted when considering therapeutic anticoagulation in patients with high-grade gliomas given the increased risk of ICH and poor prognosis after a major hemorrhage on anticoagulation. The PANWARDS score may assist clinicians in identifying the patients at greatest risk of suffering a major intracranial hemorrhage with anticoagulation 7).
PANWARDS Nomogram for Predicting Risk of Intracranial Hemorrhage
Platelets, ×109/L <125
11
125–149
8
150–174
5
175–199
3
≥200
0
Albumin, g/dL
<3.0
18
3.0–3.49
14
3.5–3.99
9
4.0–4.49
5
≥4.5
0
No history of CHF
6
Warfarin instead of rivaroxaban
7
Age, y
<55
0
55–64
4
65–74
8
75–84
13
≥85
17
Race
Black
18
Asian
9
White or other
0
Diastolic blood pressure, mm Hg
<50
0
50–69
4
70–89
9
90–109
13
≥110
17
Previous stroke or TIA
5
CHF indicates congestive heart failure; PANWARDS, platelets, albumin, no CHF, warfarin, age, race, diastolic blood pressure, stroke; and TIA, transient ischemic attack.