713 - Metastatic Breast Cancer Patient with Spontaneous Intracerebral Hemorrhage: Deep Venous Thrombosis Prophylaxis Considerations

Case Diagnosis: Spontaneous Intracerebral Hemorrhage

Case Description: A 65-year-old female with metastatic triple-negative breast cancer was admitted to acute inpatient rehabilitation due to debility. Her stay was marred by intermittent memory lapses, challenging pain management, and heightened anxiety. Despite these hurdles, she achieved notable functional improvements while inpatient. One morning, she was discovered unresponsive in her room. Subsequent evaluation revealed intracerebral hemorrhage along with a subarachnoid hemorrhage.

Discussions: Selecting an appropriate DVT prophylaxis involves assessing the delicate balance between hemorrhage and thrombosis risks. The decision is complicated by medical factors like thrombocytopenia and cancer. Thrombocytopenia does not reduce clotting risk, but may increase the risk of hemorrhage. Meanwhile, cancers heighten the risks of both hemorrhage and thrombosis. It's noteworthy that any anticoagulant usage amplifies the potential for spontaneous hemorrhage. In our case, the patient suffered a catastrophic spontaneous intracerebral hemorrhage, prompting an evaluation of DVT prophylaxis guidelines.

Conclusions: DVT prophylaxis necessitates a meticulous assessment of thrombosis and hemorrhage risks. However, a universal guide for thrombocytopenic patients' DVT prophylaxis remains absent. The exclusion of severely thrombocytopenic patients from numerous studies has left a gap in understanding anticoagulation's role in this context. The intricate interplay between thrombocytopenia and cancer further complicates decisions surrounding the initiation and cessation of thrombosis chemoprophylaxis. The relationship between thrombocytopenia and hemorrhage risk isn't linear, with cautious consideration warranted for platelet counts below 50,000. In cases of high-risk thrombosis cancer patients, DVT prophylaxis involving enoxaparin might be employed until platelet counts drop below 25,000. A comprehensive evaluation of risks and benefits in severely thrombocytopenic cancer patients necessitates a collaborative approach involving a multidisciplinary team encompassing pharmacy and hematology expertise.