Intracranial hemorrhage in patients with primary brain cancer receiving anticoagulation

Direct oral anticoagulants (DOACs) are easier to administer than low-molecular-weight heparin (LMWH) in patients with cancer, but their safety profile in patients with primary brain cancer remains uncertain. Our aim was to assess the incidence and clinical predictors of intracranial hemorrhage (ICH) in patients with primary brain cancer receiving therapeutic doses of either DOACs or LMWH. The Anticoagulation in Brain Cancer Study was an international retrospective cohort study (2014-2022) conducted in 12 hospitals on adults with primary brain cancer receiving therapeutic doses of either DOACs or LMWH for any indication or duration. The primary outcome was the occurrence of spontaneous ICH. We calculated the 12-month cumulative incidence of spontaneous ICH and determined hazard ratios (HR) to compare the risk between DOACs and LMWH, accounting for death as a competing risk. The cohort included 240 patients, 61 receiving DOAC and 179 on LMWH. The 12-month cumulative incidence of spontaneous ICH was 6.8% (95% confidence interval [CI], 2.1-15.3) with DOAC compared with 13.0% (95% CI, 8.5-18.6) in the LMWH group; HR of 0.60 (95% CI, 0.24-1.49). Death within 30 days of ICH occurred in 4 (6.5%) and 7 (3.9%) patients with DOAC and LMWH, respectively. No specific predictors of ICH were identified. Patients receiving DOACs generally had a lower bleeding risk profile (eg, less likely to have newly initiated anticoagulation after diagnosis of primary brain cancer). These data support the use of DOACs in patients with primary brain cancer who require therapeutic anticoagulation.

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Publication Details

Journal
Blood Vessels Thrombosis & Hemostasis
Published
2026-01-20
DOI
https://doi.org/10.1016/j.bvth.2026.100140
Primary Topic
Intracerebral and Subarachnoid Hemorrhage Research
Type
article
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article

Intracranial hemorrhage in patients with primary brain cancer receiving anticoagulation

Rani Barnea, Brian J. Carney, Jeffrey I. Zwicker, Jonathan Naftali et al.
Blood Vessels Thrombosis & Hemostasis
Intracerebral and Subarachnoid Hemorrhage Research
article

Intracranial hemorrhage in patients with primary brain cancer receiving anticoagulation

Rani Barnea, Brian J. Carney, Jeffrey I. Zwicker, Jonathan Naftali, Galia Spectre, Ludo F.M. Beenen, Kristen M. Sanfilippo, Ariela Arad, Benjamin Massat, Erez Halperin, Rosario Serrano, Varun Iyengar, Shira Rozenblatt, Eva N. Hamulyák, Yossi Kalish, Berna C. Özdemir, Tzu-Fei Wang, Shlomit Yust-Katz, Hugo ten Cate, Saskia Middeldorp, Harry R. Büller, Michele Hoffmann, Avi Leader, Aharon Lubetsky, Lisa Baumann Kreuziger, Ann Hoeben, Martinus P.G. Broen, Pia Raanani, Eitan Auriel, Marc Carrier
article en

Abstract

Direct oral anticoagulants (DOACs) are easier to administer than low-molecular-weight heparin (LMWH) in patients with cancer, but their safety profile in patients with primary brain cancer remains uncertain. Our aim was to assess the incidence and clinical predictors of intracranial hemorrhage (ICH) in patients with primary brain cancer receiving therapeutic doses of either DOACs or LMWH. The Anticoagulation in Brain Cancer Study was an international retrospective cohort study (2014-2022) conducted in 12 hospitals on adults with primary brain cancer receiving therapeutic doses of either DOACs or LMWH for any indication or duration. The primary outcome was the occurrence of spontaneous ICH. We calculated the 12-month cumulative incidence of spontaneous ICH and determined hazard ratios (HR) to compare the risk between DOACs and LMWH, accounting for death as a competing risk. The cohort included 240 patients, 61 receiving DOAC and 179 on LMWH. The 12-month cumulative incidence of spontaneous ICH was 6.8% (95% confidence interval [CI], 2.1-15.3) with DOAC compared with 13.0% (95% CI, 8.5-18.6) in the LMWH group; HR of 0.60 (95% CI, 0.24-1.49). Death within 30 days of ICH occurred in 4 (6.5%) and 7 (3.9%) patients with DOAC and LMWH, respectively. No specific predictors of ICH were identified. Patients receiving DOACs generally had a lower bleeding risk profile (eg, less likely to have newly initiated anticoagulation after diagnosis of primary brain cancer). These data support the use of DOACs in patients with primary brain cancer who require therapeutic anticoagulation.

Blood Vessels Thrombosis & HemostasisVol. 3(2)
University of Bern (CH), Beth Israel Deaconess Medical Center (US), Memorial Sloan Kettering Cancer Center (US), University of Ottawa (CA), Tel Aviv University (IL), Medical College of Wisconsin (US), Sheba Medical Center (IL), Hadassah Medical Center (IL), Maastricht University Medical Centre (NL), Rabin Medical Center (IL), Ottawa Hospital (CA), University Hospital of Bern (CH), St. Louis VA Medical Center (US), Versiti Blood Center of Wisconsin (US), Amsterdam University Medical Centers (NL), Instituto Nacional de Cancerología (MX), Maastro Clinic (NL), Ottawa Hospital Research Institute (CA), Saint Louis University (US), University of Amsterdam (NL)
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Intracerebral and Subarachnoid Hemorrhage Research
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