Intraventricular thrombolysis for massive intraventricular hemorrhage due to periventricular arteriovenous malformations: no absolute contraindications as rescue therapy prior to surgical repair or embolization?

Intraventricular hemorrhage (IVH) after bleeding from a cerebral aneurysm or an arteriovenous malformation (AVM) results in a high mortality. A limited number of publications have shown that intraventricular thrombolysis with e.g. recombinant tissue plasminogen activator (rt-PA) can be a therapeutic option in IVH. However, this treatment is considered as an absolute contraindication prior to the treatment of the bleeding source. We report the successful use of low-dose intraventricular thrombolysis (rt-PA) in two cases of life-threatening intraventricular hemorrhage due to periventricular AVMs as rescue therapy, even prior to source control of the bleeding. Our observations, together with nine comparable published cases, illustrate that this treatment might be useful to clear the intraventricular blood and lower intracranial pressure. It might also improve neurological outcome and mortality in these selected patients. This suggests that hemorrhage from a periventricular AVM, even before surgical resection or endovascular embolization, is not necessarily an absolute contraindication for intraventricular thrombolysis in patients with massive IVH.