Hemorrhagic Brain Metastases in Modern Neuro-Oncology: Hemostatic Risk, Surgical Decision-Making, and Integrated Therapeutic Strategies

Hemorrhagic brain metastases represent a major challenge in contemporary neuro-oncology due to their association with acute neurological deterioration, intracranial hypertension, functional impairment, and complex therapeutic decision-making. Their clinical behavior is influenced by primary tumor histology, vascular abnormalities, metastatic lesion characteristics, coagulation disturbances, and previous oncological treatments. This narrative review aimed to critically examine the determinants of intracranial bleeding, neurosurgical indications, and multimodal treatment strategies in adults with hemorrhagic brain metastases. Relevant international scientific literature, including observational cohorts, randomized clinical trials, and multidisciplinary guidelines, was analyzed through a descriptive and integrative approach, incorporating contributions from Latin America. The reviewed evidence identified melanoma, renal cell carcinoma, and thyroid carcinoma as malignancies with substantial hemorrhagic susceptibility. Tumor dimensions and pre-existing bleeding were associated with differences in hemorrhagic presentation and local disease control. Observational studies evaluating therapeutic anticoagulation did not demonstrate a uniform increase in intracranial bleeding, although important limitations remain in patients with active hemorrhage. Neurosurgical resection provides established benefits in selected patients with brain metastases, particularly regarding local control and neurological outcomes, but evidence specifically addressing hemorrhagic lesions remains limited. Stereotactic radiosurgery offers an important local treatment option, although hemorrhagic metastases may exhibit inferior local control compared with nonhemorrhagic lesions. Immunotherapy and molecularly targeted treatments have expanded therapeutic possibilities, yet their optimal integration in acute hemorrhagic presentations remains uncertain. Overall, the findings emphasize that hemorrhagic status alone should not determine treatment selection. Individualized multidisciplinary assessment incorporating neurological severity, tumor biology, hematological risk, and systemic oncological prognosis is essential. Further prospective multicenter investigations are necessary to establish standardized risk stratification and optimize therapeutic sequencing.