title: Should thrombolysis be contraindicated in patients with cerebral arteriovenous malformations?
abstract: OBJECTIVE
  To report the successful and uncomplicated use of systemic thrombolysis for massive pulmonary embolism in a patient with a known cerebral arteriovenous malformation and to suggest that the presence of an unruptured arteriovenous malformation or aneurysm should not be considered an absolute contraindication to systemic thrombolysis.
  
  
  METHODS
  Case report.
  
  
  METHODS
  A 16-bed adult neurologic/medical intensive care unit in a university hospital.
  
  
  METHODS
  A patient developed a massive pulmonary embolism the morning after elective cerebral embolization of a large unruptured cerebral arteriovenous malformation.
  
  
  METHODS
  Radial artery catheterization, arterial blood gas measurements, mechanical ventilation, vasopressors, pulmonary perfusion scan, echocardiogram, head computed tomography, heparin therapy, and systemic recombinant tissue plasminogen activator therapy.
  
  
  RESULTS
  The patient required emergent mechanical ventilation and vasopressor support for respiratory and hemodynamic failure. Echocardiogram showed acute right heart failure, and pulmonary perfusion scan demonstrated massive pulmonary embolism. Despite intravenous heparin therapy, the patient had worsening hypotension and acidosis and we therefore treated with recombinant tissue plasminogen activator. Within the next day the patient was weaned from vasopressor support and extubated. Neurologic examination remained normal, and follow-up head computed tomography revealed no evidence of intracranial hemorrhage.
  
  
  CONCLUSIONS
  Known arteriovenous malformations or aneurysms are considered a contraindication to thrombolysis, although the true risk of thrombolysis-precipitated intracranial hemorrhage is unknown. We believe that this risk is low in the setting of a previously unruptured arteriovenous malformation or aneurysm. The decision to use systemic thrombolysis in a patient with a known vascular malformation should be individualized.
authors.affiliation: Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
authors.forename: Charlotte J
authors.initials: CJ
authors.lastname: Sumner
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Golden
authors.forename: J Claude
authors.initials: JC
authors.lastname: Hemphill
mesh_terms: D000075202:Contraindications; D004621:Embolization, Therapeutic; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000150:complications* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000150:complications / Q000188:drug therapy*; D011994:Recombinant Proteins / Q000627:therapeutic use; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use
chemical_list: D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator