Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA.
Neurosurgery. 2011 Feb;68(2):E581-6; discussion E586. doi: 10.1227/NEU.0b013e31820208a6.
Intraventricular hemorrhage related to arteriovenous malformation (AVM) rupture is associated with significant morbidity and mortality. Intraventricular tissue plasminogen activator (tPA) has been used to treat spontaneous intraventricular hemorrhage. We demonstrate the successful application of endovascular occlusion to seal the rupture site of an AVM followed by intraventricular tPA.
A 32-year-old woman presented with a right frontoparietal parasagittal AVM abutting the motor cortex. The AVM was diagnosed when the patient was 13 years old, and she initially underwent conservative management. At the age of 30, the patient suffered an intracranial hemorrhage, leaving her with left hemiparesis. After rehabilitation, the patient regained ambulation; however, she remained spastic and hyperreflexic on the left side. Two years after her major hemorrhage, she presented for elective treatment of her AVM. The patient was advised to undergo staged embolization before surgical resection of her AVM. The initial embolization was uneventful. A second embolization was complicated by intraventricular hemorrhage and coma. The patient was treated with placement of an external ventricular drain followed by embolization of intranidal aneurysm. After embolization of the intranidal aneurysm the ruptured, the patient was treated with intraventricular tPA. The patient had rapid clearance of the intraventricular hemorrhage and significant improvement in her neurological examination, following commands 24 hours later and returning almost to baseline.
This case demonstrates the feasibility of treating AVM-related intraventricular hemorrhage with tPA if the rupture source can be confidently sealed interventionally. This strategy can be lifesaving but needs further study to ensure its safety.
动静脉畸形（AVM）破裂相关的脑室内出血与显著的发病率和死亡率相关。脑室内组织型纤溶酶原激活物（tPA）已被用于治疗自发性脑室内出血。我们展示了血管内闭塞术成功应用于封堵 AVM 破裂部位，随后进行脑室内 tPA 治疗。
一名 32 岁女性因右额顶矢状旁 AVM 紧贴运动皮层而就诊。该 AVM 在患者 13 岁时被诊断，最初接受保守治疗。30 岁时，患者发生颅内出血，导致左侧偏瘫。康复后，患者恢复了行走能力；但左侧仍有痉挛和反射亢进。大出血后两年，她因 AVM 行择期治疗就诊。患者被建议先进行分期栓塞，然后再进行 AVM 切除术。初次栓塞过程顺利。第二次栓塞后出现脑室内出血和昏迷。患者接受了外置脑室引流管治疗，并进行了颅内动脉瘤栓塞。颅内动脉瘤栓塞破裂后，患者接受了脑室内 tPA 治疗。患者的脑室内出血迅速清除，神经功能检查显著改善，24 小时后可按指令活动，几乎恢复到基线水平。
如果能够通过介入治疗有信心地封堵破裂源，那么使用 tPA 治疗 AVM 相关脑室内出血是可行的。这种策略可能具有救生作用，但需要进一步研究以确保其安全性。
