Question: Anticoagulation and brain mets

[pinipig523]

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So, say a patient w/ hx of lung cancer presents to you (small cell, highly metastatic). You think this might be a PE.

In addition to the CT r/o PE, do you also do a CT Head to r/o mets and look for any sign of necrotic mets before reaching for the lovenox or heparin?

I always thought that brain cancer is not a contraindication for anticoagulation - does anyone know otherwise?

How do YOU practice?

 

[Arcan57]

I would get the head CT and talk to the oncologist prior to anticoagulation if mets were present.

 

[deleted109597]

If the only thing the PE is causing is pain (not hypoxia, right heart strain, or tachycardia), then I would argue you shouldn't treat it at all, brain mets or not.
On the flip side, if they're going to die if you don't treat it, who cares if they have mets?

So my answer is pretty much no, unless someone wants me to look for them.

 

[Rendar5]

I think Arcan had the right answer, although I don't which brain mets have a tendency to bleed other than melanoma mets.

 

[EdibleEgg]

If you have mets and a PE the prognosis is terrible, but anticoagulate unless there is another contraindication.

 

[WilcoWorld]

If you'd asked me 2 weeks ago my answer would've been that I would anticoagulate w/o a head CT in the setting of metastatic disease if there is no HA/acute neuro symptoms/Hx of bleed. However I must admit that some recent medmal shenanigans have me rethinking that stance...

 

[pinipig523]

If you'd asked me 2 weeks ago my answer would've been that I would anticoagulate w/o a head CT in the setting of metastatic disease if there is no HA/acute neuro symptoms/Hx of bleed. However I must admit that some recent medmal shenanigans have me rethinking that stance...

Can you post or let me know of such shenanigans.

I seriously thought brain mets were contraindications for tPA but not coumadin.

 

[WilcoWorld]

Can you post or let me know of such shenanigans.

I seriously thought brain mets were contraindications for tPA but not coumadin.

Brain mets are not a contraindication to heparin/coumadin unless they're bleeding, which is highly unlikely in someone with no HA or neuro Sx - hence my "old" practice. The shenanigans I refered to are not related to this particular pathology. I'm taking about people getting successfully sued when a patient who declines a next-day stress test drops dead during a threesome 6 days later. That's to say that I'm worrying about getting sued for practicing good medicine.

Check back with me in a month. Hopefully I'll be back to my evidence-based self.

 

[deleted109597]

Check back with me in a month. Hopefully I'll be back to my evidence-based self.

Move to Texas. We don't have cookies, but we do have the best beer, vodka, and tacos in the country.

 

[WilcoWorld]

Move to Texas. We don't have cookies, but we do have the best beer, vodka, and tacos in the country.

And migas. Man I love migas.

 

[Pinner Doc]

So, say a patient w/ hx of lung cancer presents to you (small cell, highly metastatic). You think this might be a PE.

In addition to the CT r/o PE, do you also do a CT Head to r/o mets and look for any sign of necrotic mets before reaching for the lovenox or heparin?

I always thought that brain cancer is not a contraindication for anticoagulation - does anyone know otherwise?

How do YOU practice?

I once cared for a patient presenting with AMS. He had melanoma and ultimately it was determined the AMS was from a head bleed from the lovenox his outpatient doctor had started because of a small PE pt had developed. It's definitely a concern. I'd get a head CT and make some calls before starting anticoagulation.

 

[Groove]

Great question. My reflex answer would be that in any PE related emergent situation, I would anti coagulate, even with the history you provided. I guess what I'm saying is that if I have a clinical suspicion that the patient has a PE large enough to kill them, then I'm not wasting time with a CT of the head, because the chances of the PE killing them are greater than increasing their risk of a head bleed from brain mets. The fact that I'm scanning their chest emergently implicits that I'm concerned for a life threatening PE. So, as devil's advocate, I could equally say... what if he had a large PE and suddenly arrested while you're getting the CT Head? What's medmal going to say about that one?

I think everyone would admit that we certainly don't routinely CT Head on every cancer patient with a PE or consider that as something that would drastically change our management unless they are presenting with a concomitant clinical suspicion for CVA/ICH, or other intracranial abnormality that could also be equally emergent.

However, with the segmental or sub segmental PE patient with hx or suspicion of brain mets, yea... I guess I'd feel the same way that Arcan does in that I'd want the opinion of the oncologist as to whether there was any contraindication from his point of view for anti-coagulation.

Interesting question. I've honestly never thought to scan the heads of all the PE patients who had cancer but merely used their dx of cancer as a variable to increase my suspicion of PE. So, I guess you could say I've been more hyper focused on the PE rather than think about a potential head bleed because I consider that to be the most life threatening condition at the moment and brain mets isn't a contraindication.

I'd be curious as to what some of the attendings who have been in similar medmal cases could share... I can't imagine being sued in the ED and losing for anti coagulating a moderate PE and then the patient dying from a head bleed several days later while in the hospital.

 

[dotcb]

I think it is quite defensible to AC them w/o head CT. I would document the reasoning though (that likeliehood of mets that would bleed are extremely low w/o HA, neuro sxs, and NL neuro exam). If I found brain mets, I would d/w oncologist, and I think we would prolly AC anyway. Lytics would be a multidisciplinary discussion w/. neuro, onc, ED, and the patient.

 

[Hamhock]

Anticoagulation with heparin or coumadin is not - by pharmacology and definition - an emergency.

There's plenty of time to CTH and contact a specialist who knows more about the potential for bleeding into brain mets.

And most patients with a metastatic CA and a PE are not going to be negatively impacted by the radiation (the contrast might impact the kidneys, however). They are going to be dead pretty soon anyway.

I think it is definitely worth the time to discuss and image. PEs are rarely crashing.

Hell - how many crashing PE patients (shock/requiring pressors/requiring tpa before arrest/etc) have any of us actually seen in the ED? 10? 15?

And even if they are in this crashing situation, coumadin or heparin ain't going to help.

HH

 

[gutonc]

As the oncologist you're all going to call at some point during this case I'll add my 2 cents.

As others (HH most recently) have mentioned, anticoagulating them for a PE that's already established won't have any significant impact on that particular clot other than to keep it (hopefully) from embolizing and making things worse. So, it's urgent, but not emergent. A little diffuse cranial irradiation isn't really going to delay your treatment that much, so go for it.

If they're crashing, that's a different story, but 1mg/kg of lovenox won't help that either way. If you're thinking about pushing TPA for stroke symptoms though, a scan's probably a good idea (but that isn't the issue at hand).

As far as brain mets and bleeding goes, all brain mets can bleed, but very few actually do. The ones that I'm personally concerned about are the more vascular tumors like melanoma and renal cell. Lung, breast and most others don't worry me as much. They worry me of course, just not as much as the others. If I had an RCC patient with a moderately symptomatic segmental PE (pain but not requiring O2), I'd scan their brain first before dropping the lovenox regardless of neuro sxs. Lung or colon cancer with the same presentation and no neuro sxs? Anticoagulate and document risk/benefit.

 

[Groove]

As the oncologist you're all going to call at some point during this case I'll add my 2 cents.

As others (HH most recently) have mentioned, anticoagulating them for a PE that's already established won't have any significant impact on that particular clot other than to keep it (hopefully) from embolizing and making things worse. So, it's urgent, but not emergent. A little diffuse cranial irradiation isn't really going to delay your treatment that much, so go for it.

If they're crashing, that's a different story, but 1mg/kg of lovenox won't help that either way. If you're thinking about pushing TPA for stroke symptoms though, a scan's probably a good idea (but that isn't the issue at hand).

As far as brain mets and bleeding goes, all brain mets can bleed, but very few actually do. The ones that I'm personally concerned about are the more vascular tumors like melanoma and renal cell. Lung, breast and most others don't worry me as much. They worry me of course, just not as much as the others. If I had an RCC patient with a moderately symptomatic segmental PE (pain but not requiring O2), I'd scan their brain first before dropping the lovenox regardless of neuro sxs. Lung or colon cancer with the same presentation and no neuro sxs? Anticoagulate and document risk/benefit.

Thanks...good to know.

 

[pinipig523]

As the oncologist you're all going to call at some point during this case I'll add my 2 cents.

As others (HH most recently) have mentioned, anticoagulating them for a PE that's already established won't have any significant impact on that particular clot other than to keep it (hopefully) from embolizing and making things worse. So, it's urgent, but not emergent. A little diffuse cranial irradiation isn't really going to delay your treatment that much, so go for it.

If they're crashing, that's a different story, but 1mg/kg of lovenox won't help that either way. If you're thinking about pushing TPA for stroke symptoms though, a scan's probably a good idea (but that isn't the issue at hand).

As far as brain mets and bleeding goes, all brain mets can bleed, but very few actually do. The ones that I'm personally concerned about are the more vascular tumors like melanoma and renal cell. Lung, breast and most others don't worry me as much. They worry me of course, just not as much as the others. If I had an RCC patient with a moderately symptomatic segmental PE (pain but not requiring O2), I'd scan their brain first before dropping the lovenox regardless of neuro sxs. Lung or colon cancer with the same presentation and no neuro sxs? Anticoagulate and document risk/benefit.

When you say "vascular tumors such as melanoma and renal cell" - can you explain further?

 

[gutonc]

When you say "vascular tumors such as melanoma and renal cell" - can you explain further?

Not sure what you want here. Those tumors are (classically), very vascular and bleed like stink if you look at them sideways. Most other tumor types are (again...classically) not that vascular and tend not to bleed spontaneously.

But here's the key....If we didn't anticoagulate every patient with a PE or large DVT and cancer because we were worried about intracranial bleeds, almost nobody would die of cancer any more...they'd all die of massive PEs.

 

[pinipig523]

Not sure what you want here. Those tumors are (classically), very vascular and bleed like stink if you look at them sideways. Most other tumor types are (again...classically) not that vascular and tend not to bleed spontaneously.

But here's the key....If we didn't anticoagulate every patient with a PE or large DVT and cancer because we were worried about intracranial bleeds, almost nobody would die of cancer any more...they'd all die of massive PEs.

Got it... thanks!

Interestingly we had another patient with brain mets - I thought of your post and read up more on it. 👍

 

[omarsaleh66]

U could always just put in an ivc filter

 

[deleted109597]

I'll let you tell me how a filter helps a PE. Bonus points for using big words.

 

[gutonc]

I'll let you tell me how a filter helps a PE. Bonus points for using big words.

Dammit...beat me to it.

It also doesn't really do much for the whole "hypercoagulable state" thing inherent in cancer patients.

 

[omarsaleh66]

Filter won't do anything for the pe, but can help in preventing further clot burden especially if lovenox or heparin contraindicated.

 

[gutonc]

Filter won't do anything for the pe, but can help in preventing further clot burden especially if lovenox or heparin contraindicated.

Actually, it won't do anything to modulate the clot burden, it will just move it around. And if you haven't seen a PE in somebody with an IVC filter in place, you haven't been doing this long enough.

 

[omarsaleh66]

Actually, it won't do anything to modulate the clot burden, it will just move it around. And if you haven't seen a PE in somebody with an IVC filter in place, you haven't been doing this long enough.

So in a guy w brain mets, and a pe, u would just anticoagulate? If the mets were hemmorhagic u still wouldn't use a filter,? Thanks

 

[gutonc]

So in a guy w brain mets, and a pe, u would just anticoagulate? If the mets were hemmorhagic u still wouldn't use a filter,? Thanks

I didn't say I wouldn't use a filter. Just that it's largely a moot issue at that point.

And this is so far off the original question (PE + cancer, do you scan head before lovenox) that I'm not sure why we're talking about it.

 

[la gringa]

And if you haven't seen a PE in somebody with an IVC filter in place, you haven't been doing this long enough.

i have to explain this to nurses, patients, even fellow EP's all the time.... cuts the risk but it isn't impossible!!! also part of the reason my mother is on coumadin w/ a filter... until her risk/benefit is not in favor of coumadin, she'll stay on it.