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.