Use of intraventricular tissue plasminogen activator and Guglielmi detachable coiling for the acute treatment of casted ventricles from cerebral aneurysm hemorrhage: Two technical case reports

OBJECTIVE AND IMPORTANCE: We report two cases of massive intraventricular hemorrhage resulting from subarachnoid hemorrhage. Both patients had experienced a ruptured cerebral aneurysm and were initially moribund. The patients were treated with Guglielmi detachable coiling and then administration of intraventricular tissue plasminogen activator (tPA). Rapid clot resolution was demonstrated radiographically in both. Both patients survived and had a meaningful functional neurological recovery. These are the first reported cases of the acute use of intraventricular tPA after Guglielmi detachable coiling treatment for ruptured cerebral aneurysm. CLINICAL PRESENTATION: A 59-year-old woman and a 44-year-old man presented with high-grade subarachnoid hemorrhage. Both had had extensive casting of their ventricular systems with blood. INTERVENTION: The patients were treated with Guglielmi detachable coiling thrombosis of the aneurysm and then intraventricular administration of tPA for dissolution of blood clots. Both patients survived; one is able to carry out activities of daily living with moderate assistance, and the other is able to communicate with his family. CONCLUSION: This is a novel method to manage patients with high-grade aneurysms with massive intraventricular blood clots. The tPA reduced the mass effect of the blood clot, possibly helping to improve the neurological grade; in addition, the administration of tPA helped keep the external ventricular drains functional, enabling treatment of the acute hydrocephalus. The safety of administering tPA after endovascular thrombosis was demonstrated in these two patients. Further investigation is required to determine the applicability of this approach on a broader scale.