Thrombolysis for intraventricular hemorrhage after endovascular aneurysmal coiling
Objective and Importance: Current applications of lytic therapy for intraventricular hemorrhage (IVH) rely on exclusion of vascular abnormalities as etiology. Its use in patients with recently coiled aneurysms remains far from considered safe. We report a patient with subara chnoid hemorrhage (SAH) and massive IVH from aneurysmal rupture, which was safely treated with intraventricular recombinant tissue plasminogen activator (rt-PA) after endovascular coiling. We also review two other similar cases reported in the literature.
Clinical Presentation: A 61-year-old man presented with a ruptured anterior communicating artery aneurysm causing SAH and IVH (Hunt & Hess grade IV, Fisher grade III with IVH). During coiling of the aneurysm, extravasation of contrast was noted on fluoroscopy. Follow-up head computed tomography (CT) scan showed casted ventricles. Once in the intensive care unit, the patient progressed to coma, which did not improve with external ventricular drainage alone.
Intervention: After endovascular coiling of the aneurysm, intraventricular rt-PA was administered. Isovolemic injections of 2 mg rt-PA every 12 hours were performed for a total of four doses. No clinical or radiological evidence of worsening SAH/IVH was documented. At the time of discharge, the patient was awake but requiring assistance with activities of daily living.
Conclusion: We report the safe administration of intraventricular rt-PA after endovascular coiling of a ruptured cerebral aneurysm. Two other similar cases were found in the literature and are reviewed. Hindrance of aneurysmal cavity thrombosis by early administration of rt-PA (increasing the risk of rerupture) remains a widespread concern. The lack of such instances should therefore be acknowledged. We propose that inclusion of such patients in trials assessing safety/efficacy of thrombolytic theray in the treatment of patients with intracranial hemorrhage should be carefully considered.
Key WordsSubarachnoid hemorrhage intraventricular hemorrhage recombinant tissue plasminogen activator Guglielmi detachable coils
Yasui T, Kishi H, Komiyama M, Iwai Y, Yamanaka K, Nishikawa M. Very poor prognosis in cases with extravasation of the contrast medium during angiography. Surg Neurol 1996;45:560–564; discussion 564–565.PubMedCrossRefGoogle Scholar
Hanley DF, Williams MA, Naff N. Intracranial hemorrhage: time for an intervention. Crit Care Med 1999;27:477–478.PubMedCrossRefGoogle Scholar
Naff NJ. Intraventricular hemorrhage in adults. Curr Treat Options Neurol 1999;1:173–178.PubMedCrossRefGoogle Scholar
Naff NJ, Tuhrim S. Intraventricular hemorrhage in adults: complications and treatment. New Horiz 1997;5:359–363.PubMedGoogle Scholar
Claassen J, Bernardini GL, Kreiter K, et al. Effect of cisternal and ventricular blood on risk of delayed cerebral ischemia after subarachnoid hemorrhage: the Fisher Scale revisited. Stroke 2001;32:2012–2020.PubMedGoogle Scholar
Tuhrim S, Dambrosia JM, Price TR, Mohr JP, Wolf PA, Heyman A, Kase CS. Prediction of intracerebral hemorrhage survival. Ann Neurol 1988;24:258–263.PubMedCrossRefGoogle Scholar
Tuhrim S, Horowitz DR, Sacher M, Godbold JH. Volume of ventricular blood is an important determinant of outcome in supratentorial intracerebral hemorrhage. Crit Care Med 1999;27:617–621.PubMedCrossRefGoogle Scholar
Adams RE, Diringer MN. Response to external ventricular drainage in spontaneous intracerebral hemorrhage with hydrocephalus. Neurology 1998;50:519–523.PubMedGoogle Scholar
Naff NJ, Carhuapoma JR, Williams MA. Treatment of intraventricular hemorrhage with urokinase: effects on 30-day survival. Stroke 2000;31:841–847.PubMedGoogle Scholar
Naff NJ, Hanley DF, Keyl PM, et al. Intraventricular thrombolysis speeds blood clot resolution: results of a pilot, prospective, randomized, double-blind, controlled trial. Neurosurgery 2004;54:577–583; discussion 583–574.PubMedCrossRefGoogle Scholar
Naff NJ, Williams MA, Rigamonti D, Keyl PM, Hanley DF. Blood clot resolution in human cerebrospinal fluid: evidence of firstorder kinetics. Neurosurgery 49:614–619; discussion 619–621, 2001.PubMedCrossRefGoogle Scholar
Seifert V, Stolke D, Zimmermann M, Feldges A. Prevention of delayed ischaemic deficits after aneurysmal subarachnoid haemorrhage by intrathecal bolus injection of tissue plasminogen activator (rTPA). A prospective study. Acta Neurochir (Wien) 1994;128:137–143.CrossRefGoogle Scholar
Findlay JM, Kassell NF, Weir BK, et al. Arandomized trial of intraoperative, intrascisternal tissue plasminogen activator for the prevention of vasospasm. Neurosurgery 1995;37:168–176.PubMedCrossRefGoogle Scholar
Findlay JM, Weir BK, Kanamaru K, Grace M, Gordon P, Baughman R, Howarth A. Intrathecal fibrinolytic therapy after subarachnoid hemorrhag: dosage study in a primate model and review of the literature. J Neurosurg 1989;69:723–735.Google Scholar
Findlay JM, Weir BK, Steinke D, Tanabe T, Gordon P, Grace M. Effect of intrathecal thrombolytic therapy on subarachnoid clot and chronic vasospasm in a primate model of SAH. J Neurosurg 1988;69:723–735.PubMedCrossRefGoogle Scholar
Schmidt JH, Christenson JT. Intraoperative use of rtPA for subarachnoid hemorrhage. W V Med J 90:98–100, 1994.PubMedGoogle Scholar
Seifert V. Intrathecal fibrinolysis using recombinant tissue plasminogen activator (rTPA) for prevention of cerebral vasospasm and delayed ischaemic deficits after aneurysmal subarachnoid haemorrhage. Experimental and clinical data. Neurol Res 1994;16:54–58.PubMedGoogle Scholar
Stolke D, Seifert V. Single intracisternal bolus of recombinant tissue plasminogen activator in patients with aneurysmal subarachnoid hemorrhage: preliminary assessment of efficacy and safety in an aopen clinical study. Neurosurgery 1992;30:877–881.PubMedCrossRefGoogle Scholar
Tomasello F, D’Avella D. Intracisternal rt-PA during early surgery for aneurysmal subarachnoid hemorrhage: an Italian report. J Neurosurg Sci 1993;37:71–75.PubMedGoogle Scholar
Ezura M, Takahashi A, Ogasawara K, Yoshimoto T. Intra-aneurysmal GDC embolization followed by intrathecal tPA administration for poor-grade basilar tip aneurysm. Surg Neurol 197;47:144–147; discussion 147–148.Google Scholar
Bavinzski G, Talazoglu V, Killer M, Richling B, Gruber A, Gross CE, Plenk H. Jr. Gross and microscopic histopathological findings in aneurysms of the human brain treated with Guglielmi detachable coils. J Neurosurg 1999;91:284–293.PubMedGoogle Scholar
Murayama Y, Vinuela F, Tateshima S, Gonzales NR, Song JK, Mahdavieh H, Iruela-Arispe L. Cellular responses of bioabsorvable polymeric material and Guglielmi detachable coil in experimental aneurysms. Stroke 2002;33:1120–1128.PubMedCrossRefGoogle Scholar
Azmi-Ghadimi H, Heary RF, Farkas JE, Hunt CD. Use of intraventricular tissue plasminogen activator and Guglielmi detachable coiling for the acute treatment of casted ventricles from cerebral aneurysm hemorrhage: two technical case reports. Neurosurgery 2002;50:421–424; discussion 424–425.PubMedCrossRefGoogle Scholar
Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002;360:1267–1274.PubMedCrossRefGoogle Scholar