What is the management approach for a patient with melanoma, brain metastasis, superior sagittal sinus thrombosis, and significant pulmonary embolism who presents with an active brain bleed?

Management of Active Brain Bleed in Melanoma Patient with Brain Metastasis, Sagittal Sinus Thrombosis, and Pulmonary Embolism

In a patient with melanoma brain metastasis presenting with active intracranial bleeding, emergency surgical decompression takes absolute priority over anticoagulation, even in the presence of life-threatening pulmonary embolism and sagittal sinus thrombosis. 1, 2

Immediate Surgical Management

Perform urgent craniotomy with surgical excision to control the active hemorrhage and relieve mass effect. 2 This is the first emergent priority to prevent brain herniation syndromes and irreversible neurologic injury. 1

• Emergency surgery is indicated when acute symptoms of raised intracranial pressure are present, which is the typical presentation with tumoral intracranial bleeding. 2
• Consider selective arterial embolization if bleeding is ongoing and surgical control is inadequate. 2
• Do not delay surgical intervention to pursue systemic therapy first—CNS treatment takes priority. 2

Anticoagulation Decision During Active Bleeding

Hold all anticoagulation during the acute bleeding phase. While the active hemorrhage is ongoing, therapeutic anticoagulation is absolutely contraindicated regardless of the severity of PE or sinus thrombosis. 1, 2

Critical Risk Assessment for This Patient

Your patient has three high-risk features that dramatically increase intracranial hemorrhage risk with anticoagulation:

• Melanoma histology: Confers a 6.46-fold increased risk of symptomatic ICH compared to other primaries when anticoagulated. 3
• Active/recent intracranial bleeding: Patients with prior ICH have 2.20-fold higher risk versus those without prior ICH (p<0.001). 3
• Untreated brain metastasis with hemorrhage: Melanoma brain metastases have higher spontaneous bleeding tendency. 4

Post-Surgical Anticoagulation Strategy

After surgical control of hemorrhage and hemostasis is confirmed (typically 24-72 hours post-operatively with repeat imaging showing no active bleeding):

For the Pulmonary Embolism

Resume anticoagulation with low molecular weight heparin (LMWH) as the preferred agent. 1, 5, 2

• LMWH is more effective than vitamin K antagonists in reducing VTE recurrence without increasing major bleeding risk. 1
• The risk of intracranial hemorrhage in melanoma brain metastases patients treated with therapeutic anticoagulation is approximately 4% but is acceptable when VTE is established. 6
• Despite increased bleeding risk, established symptomatic VTE (DVT/PE) is a strong indication for anticoagulation. 5

For the Superior Sagittal Sinus Thrombosis

Treat with LMWH despite the intracranial location of thrombosis. 1

• Intracranial venous sinus occlusion should be treated with LMWH, though high-quality evidence is limited. 1
• Historical data shows that anticoagulation in sagittal sinus thrombosis with pulmonary emboli results in statistically significant better outcomes despite the 95.6% mortality rate when both conditions coexist. 7
• The mortality risk from untreated sagittal sinus thrombosis and PE far exceeds the bleeding risk from careful anticoagulation post-surgery. 7

Specific Dosing and Monitoring

• Ensure platelet count >50 × 10^9/L before initiating full-dose anticoagulation. 5
• If platelets are 20-50 × 10^9/L, consider half-dose LMWH with close monitoring. 5
• Adjust anticoagulation based on platelet count, particularly if receiving chemotherapy. 5

Alternative if Anticoagulation Cannot Be Resumed

Inferior vena cava (IVC) filter placement is NOT recommended as a routine alternative. 5, 8

• IVC filters have high failure rates (40% recurrent thromboembolic events) without improved survival or reduced ICH in brain tumor patients. 5, 8
• If an IVC filter is placed in the acute bleeding phase, it should be temporary with plans to remove once anticoagulation can be safely resumed. 4

Post-Operative Local Control

After surgical resection:

• Administer post-operative radiation therapy to the resection cavity to improve local control. 2
• Obtain baseline brain MRI within 6 months of treatment completion. 2

Systemic Therapy Selection

Once the acute crisis is managed:

• Ipilimumab-nivolumab combination is the preferred first-line treatment for melanoma brain metastases, achieving intracranial response rates of approximately 50%. 2
• If BRAF-mutated, combined BRAF/MEK inhibition achieves intracranial response rates up to 60%. 2
• Do not withhold immunotherapy indefinitely due to prior intracranial hemorrhage—surgery followed by immunotherapy offers the best long-term outcomes. 2

Critical Pitfalls to Avoid

• Do not use vitamin K antagonists in this setting due to unpredictable dose response and higher bleeding risk. 5
• Do not place prophylactic IVC filter instead of anticoagulation—filters fail frequently and don't improve outcomes. 5, 8
• Do not assume anticoagulation is absolutely contraindicated—brain metastases alone are not an absolute contraindication when VTE is established. 5
• Do not delay repeat imaging—obtain CT or MRI 24-48 hours post-surgery to confirm hemostasis before considering anticoagulation. 5

Ongoing Monitoring

• Perform regular neurological assessments to detect early signs of recurrent intracranial bleeding. 5
• Monitor platelet counts regularly, especially during chemotherapy. 5
• Maintain close surveillance with history, physical examination, and endoscopic inspection every 1-3 months in year 1. 2