Recombinant tissue plasminogen activator in the treatment of intraventricular hemorrhage secondary to periventricular arteriovenous malformation before surgery: case report.
OBJECTIVE
Intraventricular hemorrhage (IVH) is known to cause acute obstructive hydrocephalus, refractory elevated intracranial pressures (ICPs), and lowered cerebral perfusion pressures, leading to cortical ischemia. Frequent obstruction of external ventricular drains as a result of thrombus is a recurring theme. We present a case of IVH secondary to periventricular arteriovenous malformation (AVM) that was not visible at admission angiography and was treated by intraventricular infusion of recombinant tissue plasminogen activator before surgical intervention.


METHODS
An 11-year-old boy presented with acute onset of headache followed by two seizures, loss of consciousness, decerebration, right temporal hematoma, IVH, and acute obstructive hydrocephalus.


METHODS
A right external ventricular drain was placed but functioned poorly. ICP could not be controlled by conventional methods. Five milligrams of recombinant tissue plasminogen activator was injected into the ventricular system via the external ventricular drain. This was repeated daily for 4 days. This treatment resulted in progressive improvement in ICP and clinical status. Once the clot partially cleared, magnetic resonance imaging and magnetic resonance angiography suggested the presence of a right periventricular arteriovenous malformation, which was confirmed by angiography and subsequently resected.


CONCLUSIONS
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.
Kumar
Krishna
K
Department of Surgery, Section of Neurosurgery, Regina General Hospital, University of Saskatchewan, Regina, Saskatchewan, Canada. krishna.kumar@rqhealth.ca
Demeria
Denny D
DD
Verma
Ashok
A
D002533:Cerebral Angiography; D002543:Cerebral Hemorrhage / Q000601:surgery*; D002552:Cerebral Ventricles / Q000098:blood supply*; D002648:Child; D003399:Craniotomy; D006801:Humans; D006849:Hydrocephalus / Q000188:drug therapy; D002538:Intracranial Arteriovenous Malformations / Q000601:surgery*; D007427:Intracranial Pressure / Q000187:drug effects; D008279:Magnetic Resonance Imaging; D008297:Male; D011292:Premedication; D011994:Recombinant Proteins / Q000008:administration & dosage; D013702:Temporal Lobe / Q000098:blood supply*; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D014057:Tomography, X-Ray Computed; D014696:Ventriculostomy
D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator