Hall Bradley, Parker Dennis, Carhuapoma J Ricardo
Department of Neurosurgery, Providence Hospital and Medical Centers, Southfield, MI, USA.
Neurocrit Care. 2005;3(2):153-6. doi: 10.1385/NCC:3:2:153.
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 subarachnoid 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.
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.
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.
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 therapy in the treatment of patients with intracranial hemorrhage should be carefully considered.
目前溶纤疗法用于脑室内出血（IVH）时，需排除血管异常作为病因。该疗法用于近期已行动脉瘤栓塞术的患者仍远未被认为是安全的。我们报告了1例因动脉瘤破裂导致蛛网膜下腔出血（SAH）和大量IVH的患者，在血管内栓塞术后安全地接受了脑室内重组组织型纤溶酶原激活剂（rt-PA）治疗。我们还回顾了文献中报道的另外2例类似病例。
1例61岁男性患者，因前交通动脉瘤破裂导致SAH和IVH（Hunt&Hess分级IV级，Fisher分级III级伴IVH）。在动脉瘤栓塞过程中，透视时发现造影剂外渗。后续头颅计算机断层扫描（CT）显示脑室铸型。患者入住重症监护病房后陷入昏迷，单纯行脑室外引流病情未改善。
动脉瘤血管内栓塞术后，给予脑室内rt-PA治疗。每12小时等容注射2mg rt-PA，共注射4剂。未记录到SAH/IVH恶化的临床或影像学证据。出院时，患者清醒，但日常生活活动需要协助。
我们报告了1例破裂性脑动脉瘤血管内栓塞术后安全给予脑室内rt-PA治疗的病例。在文献中发现并回顾了另外2例类似病例。早期给予rt-PA会阻碍动脉瘤腔内血栓形成（增加再破裂风险），这仍是一个普遍关注的问题。因此，应认识到未出现此类情况。我们建议，在评估溶栓治疗颅内出血患者安全性/有效性的试验中，应仔细考虑纳入此类患者。
