Introduction

Venous thromboembolism (VTE) is a significant cause of mortality in patients with cancer. The risk of major bleeding of VTE with unfractionated heparin (UFH) is less than 3%, however, in patients with cancer, this risk is higher. We present a complex decision-making case of a colon cancer patient treated for pulmonary embolism, who developed an intracerebellar hemorrhage.

Case description

61-year-old man with past medical history of alcohol abuse, colon cancer diagnosed 3 months prior to admission on chemotherapy presented due to one week of fevers and chills, shortness of breath. He was admitted for sepsis, with MRSA bacteremia and endocarditis from an infected port catheter. On computerized tomography (CT) angiogram, he was found to have a pulmonary embolism, with no right ventricular strain. Patient was started on anticoagulation with unfractionated heparin drip. On day 7 of admission, he had an acute change in mental status, barely arousable, and shallow breathing. He was intubated for airway protection. CT brain showed acute large cerebellar hemorrhage in the posterior fossa with compression and displacement of right lateral and 4th ventricle, and another one adjacent to sagittal sinus. Patient received treatment with protamine and neuroprotective measures. However, he had a poor neurological exam with only preservation of brainstem reflexes, ICH score of 4 points (30-day mortality rate of 97%), and was deemed not a good candidate for neurosurgery. The next day patient’s neurological status was improved; he was awake and following basic commands, hemorrhage was stable and an extraventricular drain was placed. Patient’s hospital course was long and complicated by renal failure. Eventually was extubated, and recovered some functionality.

Discussion

Bleeding is the primary complication of anticoagulation. The treatment relies on stopping the anticoagulant, use of specific reversal agents, and considering prohemostatic agents and modalities that may remove anticoagulant. Management of intracerebral hemorrhage is also focused on neuroprotective measures and in certain cases emergent neurosurgery. Complex decision-making occurs when patients have multiple risk factors for bleeding (age, renal function, metastatic cancer) and at the same time are hypercoagulable. Cancer patients with venous thrombosis are more likely to develop recurrent VTE and major bleeding during anticoagulant treatment, thus there are specific guidelines for oncologic patients. Conclusion

The treatment of cancer-related VTE is preferable with LMWH, although UFH is more commonly used despite having more risk of bleeding in this population. Personalized treatment incorporating risk of bleed and preferences is essential. Adjustments and choice of anticoagulation should be done based on patient’s characteristics. Future research is needed to focus on optimizing risk assessment tools and biomarkers to prevent bleeding.

References

1. Streiff, M.B., Abutalib, S.A., Farge, D., Murphy, M., Connors, J.M. and Piazza, G. (2021), Update on Guidelines for the Management of Cancer-Associated Thrombosis. The Oncol, 26: e24-e40. https://doi.org/10.1002/onco.13596
2. Mark A. Crowther, Theodore E. Warkentin; Bleeding risk and the management of bleeding complications in patients undergoing anticoagulant therapy: focus on new anticoagulant agents. Blood 2008; 111 (10): 4871–4879. doi: https://doi.org/10.1182/blood-2007-10-120543
3. Khorana AA, Mackman N, Falanga A, et al. Cancer-associated venous thromboembolism. Nat Rev Dis Primers. 2022;8(1):11. Published 2022 Feb 17. doi:10.1038/s41572-022-00336-y