Systemic hemostasis with recombinant-activated factor VII followed by local thrombolysis with recombinant tissue plasminogen activator in intraventricular hemorrhage.
BACKGROUND
A 51-year-old woman on warfarin thromboprophylaxis for transient ischemic attacks developed sudden onset nausea, vomiting, and decreased mental status, rapidly becoming comatose. Head computed tomography (CT) showed intracerebral hemorrhage, extending into all ventricular chambers, and acute obstructive hematocephalus requiring urgent ventricular drainage. CT angiogram showed no evidence of an aneurysm or vascular malformation.


METHODS
The pretreatment international normalized ratio (INR) of 4.9 was rapidly corrected with recombinant activated factor VII and an external ventricular drain was placed. Despite accurate positioning, the ventriculostomy thrombosed and became nonfunctional. Recombinant tissue plasminogen activator was given intraventricularly and resulted in partial ventricular decompression within 24 hours, with dramatic improvement in the patient's level of consciousness.


RESULTS
Repeated intraventricular fibrinolysis resulted in further reduction of the intraventricular hematoma within a few days and a good patient outcome. The patient did not require permanent ventricular shunt.


CONCLUSIONS
To our knowledge, this is the first reported case of combined systemic enhancement of hemostasis and local fibrinolysis as a life-saving measure in intracranial hemorrhage.
Ionita
Catalina C
CC
Duke Neurosciences Critical Care Unit, Department of Medicine/Neurology, Duke University Medical Center, Durham, NC 27710, USA. ccionita@yahoo.com
Ferrara
Joseph
J
McDonagh
David L
DL
Grossi
Peter
P
Graffagnino
Carmelo
C
D000925:Anticoagulants / Q000627:therapeutic use; D002543:Cerebral Hemorrhage / Q000150:complications* / Q000188:drug therapy*; D015942:Factor VIIa / Q000627:therapeutic use*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006406:Hematoma / Q000188:drug therapy / Q000209:etiology; D006489:Hemostatic Techniques; D006801:Humans; D020767:Intracranial Thrombosis / Q000188:drug therapy* / Q000209:etiology; D008875:Middle Aged; D011994:Recombinant Proteins; D013788:Thalamus / Q000098:blood supply / Q000473:pathology; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014859:Warfarin / Q000627:therapeutic use
D000925:Anticoagulants; D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D014859:Warfarin; D015942:Factor VIIa; D010959:Tissue Plasminogen Activator