title: [Cerebrovascular malformation revealed during the prethrombolysis workup in acute ischemic stroke. Impact on therapeutic decision making].
abstract: Intravenous recombinant tissue plasminogen activator for acute ischemic stroke is contraindicated in patients harboring an asymptomatic intracranial vascular malformation, whether it is incidentally discovered at the time of the initial cerebral imaging or previously known. Because thrombolysis is associated with a risk of serious intracerebral hemorrhage, it is theoretically possible that this treatment increases the risk of bleeding or rupture of these malformations. However, this risk seems very low in clinical practice. We report two cases, one with a probable brainstem cavernous malformation treated with alteplase for a supratentorial ischemic stroke who developed just after treatment a fatal brainstem hemorrhage, and another one with asymptomatic dural arteriovenous fistula, treated by endovascular thrombectomy solely. This approach was safe and effective, and the patient had an endovascular embolization of the fistula one month later as it became symptomatic. Based on the literature, we discuss the bleeding risk of asymptomatic intracranial vascular malformations in acute ischemic stroke patients treated with alteplase, depending on the type of malformation (intracranial aneurysm, arteriovenous and cavernous malformation or fistula), and the alternative therapeutic options.
authors.affiliation: Unité neurovasculaire (B.G.), service de neuroradiologie diagnostique et interventionnelle (F.T.), hôpital Laënnec, CHU de Nantes, 44093 Nantes cedex, France. Electronic address: benoit.guillon@chu-nantes.fr.
authors.forename: B
authors.initials: B
authors.lastname: Guillon
authors.affiliation: Unité neurovasculaire (B.G.), service de neuroradiologie diagnostique et interventionnelle (F.T.), hôpital Laënnec, CHU de Nantes, 44093 Nantes cedex, France.
authors.forename: F
authors.initials: F
authors.lastname: Toulgoat
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000150:complications / Q000188:drug therapy* / Q000601:surgery; D020785:Central Nervous System Vascular Malformations / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000628:therapy; D002533:Cerebral Angiography; D002543:Cerebral Hemorrhage / Q000139:chemically induced / Q000517:prevention & control; D000075202:Contraindications; D003657:Decision Making; D004621:Embolization, Therapeutic; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications / Q000000981:diagnostic imaging; D008279:Magnetic Resonance Imaging; D011149:Pons / Q000098:blood supply; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000627:therapeutic use; D012306:Risk; D017131:Thrombectomy; D015912:Thrombolytic Therapy / Q000009:adverse effects; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use
chemical_list: D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator
keywords: Anévrisme intracrânien; Cerebrovascular malformation; Infarctus cérébral; Intracranial aneurysm; Ischemic stroke; Malformation vasculaire cérébrale; Thrombolyse; Thrombolysis