Recombinant Tissue Plasminogen Activator in the Treatment of Intraventricular Hemorrhage Secondary to Periventricular Arteriovenous Malformation before Surgery: Case Report

Kumar, Krishna; Demeria, Denny; Verma, Ashok

doi:10.1227/01.neu.0000053028.06474.c6

“…Some case reports in the literature describe the safe use of tissue plasminogen activator in patients with IVH and an unsecured BAVM or aneurysm. 39,49 We do not recommend the use of intraventricular thrombolytics in patients with unsecured vascular lesions because of the potential catastrophic outcome. 66 Independent of the grading system used, the surgical outcome for BAVM resection is directly related to the angioarchitecture and location of the BAVM.…”

Section: Microsurgerymentioning

confidence: 99%

Management of intracranial aneurysms associated with arteriovenous malformations

Flores

¹

,

Klinger

²

,

Rickert

³

et al. 2014

FOC

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Intracranial or brain arteriovenous malformations (BAVMs) are some of the most interesting and challenging lesions treated by the cerebrovascular neurosurgeon. It is generally believed that the combination of BAVMs and intracranial aneurysms (IAs) is associated with higher hemorrhage rates at presentation and higher rehemorrhage rates and thus with a more aggressive course and natural history. There is wide variation in the literature on the prevalence of BAVM-associated aneurysms (range 2.7%–58%), with 10%–20% being most often cited in the largest case series. The risk of intracranial hemorrhage in patients with unruptured BAVMs and coexisting IAs has been reported to be 7% annually, compared with 2%–4% annually for those with BAVM alone. Several different classification systems have been applied in an attempt to better understand the natural history of this combination of lesions and implications for treatment. Independent of the classification used, it is clear that a few subtypes of aneurysms have a direct hemodynamic correlation with the BAVM itself. This is exemplified by the fact that the presence of a distal flow-related or an intranidal aneurysm appears to be associated with an increased hemorrhage risk, when compared with an aneurysm located on a vessel with no direct supply to the BAVM nidus. Debate still exists regarding the etiology of the association between those two vascular lesions, the subsequent implications for patients’ risk of hemorrhagic stroke, and finally the determination of which patients warrant treatment and when. The ultimate goals of the treatment of a BAVM associated with an IA are to prevent hemorrhage, avoid stepwise neurological deterioration, and eliminate the mortality risk associated with recurrent hemorrhagic events. The treatment is only justifiable if the risks associated with an intervention are lower than or equivalent to the long-term risks of disability or mortality caused by the lesion itself. When faced with this difficult decision, a few questions need to be answered by the treating neu-rosurgeon: What is the mode of presentation? What is the symptomatic lesion? Which one of the lesions bled? What is the relationship between the BAVM and IA? Is it possible to safely treat both BAVM and IA? The objective of this review is to discuss the demographics, natural history, classification, and strategies for management of BAVMs associated with IAs.

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“…In the reports on rtPA use in ruptured AVMs, rtPA doses ranged from 2 to 5 mg every 12 h 1 2 5 7. There were no differences in the rate of re-haemorrhage across the different doses 5. Given the variations in dosing, we believe that the minimum effective dose of rtPA should be administered in the setting of a recently ruptured AVM where re-rupture is a concern.…”

Section: Discussionmentioning

confidence: 96%

“…In the phase II CLEAR-IVH trial, patients with spontaneous IVH received 3 mg/3 mL of rtPA every 12 h 10. In the reports on rtPA use in ruptured AVMs, rtPA doses ranged from 2 to 5 mg every 12 h 1 2 5 7. There were no differences in the rate of re-haemorrhage across the different doses 5.…”

Section: Discussionmentioning

confidence: 99%

Republished: Intraventricular thrombolysis after endovascular treatment of a ruptured arteriovenous malformation

Wang

¹

,

Ray

²

,

Hu

³

2016

J NeuroIntervent Surg

1

0

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Intraventricular haemorrhage (IVH) secondary to arteriovenous malformation (AVM) rupture carries significant morbidity and mortality. External ventricular drainage of IVH is frequently complicated by thrombus formation within the ventricular catheter and therefore often unsuccessful at treating hydrocephalus in this setting. Intraventricular administration of recombinant tissue-type plasminogen activator (rtPA) has proved successful in the treatment of spontaneous panventricular haemorrhage. However, usage of rtPA is contraindicated in the setting of a ruptured AVM or aneurysm in which the bleeding source has not been secured. There are only a few reports of intraventricular thrombolysis in the treatment of IVH from AVM rupture. We present the case of successful application of rtPA to treat IVH after endovascularly securing the haemorrhage site of the AVM. Intraventricular thrombolysis remains an option for the treatment of IVH in the setting of AVM rupture and should be considered on a case-by-case basis.

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“…In the phase II CLEAR-IVH trial, patients with spontaneous IVH received 3 mg/3 mL of rtPA every 12 h. 10 In the reports on rtPA use in ruptured AVMs, rtPA doses ranged from 2 to 5 mg every 12 h. 1 2 5 7 There were no differences in the rate of re-haemorrhage across the different doses. 5 Given the variations in dosing, we believe that the minimum effective dose of rtPA should be administered in the setting of a recently ruptured AVM where re-rupture is a concern. In our case, 1 mg of rtPA twice daily was effective.…”

Section: Discussionmentioning

confidence: 99%

Intraventricular thrombolysis after endovascular treatment of a ruptured arteriovenous malformation

Wang

¹

,

Ray

²

,

Hu

³

2016

BMJ Case Reports

0

View full text Add to dashboard Cite

Intraventricular haemorrhage (IVH) secondary to arteriovenous malformation (AVM) rupture carries significant morbidity and mortality. External ventricular drainage of IVH is frequently complicated by thrombus formation within the ventricular catheter and therefore often unsuccessful at treating hydrocephalus in this setting. Intraventricular administration of recombinant tissue-type plasminogen activator (rtPA) has proved successful in the treatment of spontaneous panventricular haemorrhage. However, usage of rtPA is contraindicated in the setting of a ruptured AVM or aneurysm in which the bleeding source has not been secured. There are only a few reports of intraventricular thrombolysis in the treatment of IVH from AVM rupture. We present the case of successful application of rtPA to treat IVH after endovascularly securing the haemorrhage site of the AVM. Intraventricular thrombolysis remains an option for the treatment of IVH in the setting of AVM rupture and should be considered on a case-by-case basis.

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Recombinant Tissue Plasminogen Activator in the Treatment of Intraventricular Hemorrhage Secondary to Periventricular Arteriovenous Malformation before Surgery: Case Report

Abstract: Recombinant tissue plasminogen activator is effective in resolving IVH causing obstructive hydrocephalus and uncontrollable ICP posing a life-threatening situation, secondary to ruptured arteriovenous malformation, before surgical intervention.

Cited by 22 publications

References 16 publications

Management of intracranial aneurysms associated with arteriovenous malformations

Management of intracranial aneurysms associated with arteriovenous malformations

Republished: Intraventricular thrombolysis after endovascular treatment of a ruptured arteriovenous malformation

Intraventricular thrombolysis after endovascular treatment of a ruptured arteriovenous malformation

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