Intra-arterial urokinase for treatment of retrograde thrombosis following resection of an arteriovenous malformation

Case report

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✓ Retrograde thrombosis of feeding arteries is a potentially catastrophic complication occasionally reported following resection of arteriovenous malformations (AVM's). No successful therapy for this condition, which causes postoperative stroke, has previously been reported. A case of retrograde thrombosis of the left middle cerebral artery immediately following resection of a parietal AVM is reported in a patient with a retained intra-arterial catheter from preoperative embolization. The administration of urokinase within 4 hours of surgery resulted in dramatic clinical and angiographic improvement without hemorrhagic complications. While urokinase is considered highly experimental in this setting, this case demonstrates that thrombolytic agents should be viewed as therapeutic options worthy of further investigation.

Article Information

Address reprint requests to: Jeffrey R. Kirsch, M.D., Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Blalock 1410, Baltimore, Maryland 21205.

© AANS, except where prohibited by US copyright law.

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Figures

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    Initial selective left internal carotid arteriograms, lateral (left) and anteroposterior (right) views, demonstrating a 5-cm retrorolandic conical arteriovenous malformation nidus with a complex pattern of superficial and deep draining veins. The primary arterial feeder is the left middle cerebral artery.

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    Selective left internal carotid arteriograms obtained 4 weeks after embolization and 1 day before surgery, lateral (left) and anteroposterior (right) views. A significant reduction in the size of the arteriovenous malformation nidus is seen. The retained catheter in the partially thrombosed left middle cerebral artery is marked by arrows.

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    Left: Selective left internal carotid arteriogram obtained within 4 hours after surgery showing complete thrombosis of the left middle cerebral artery (arrow). Right: Left internal carotid arteriogram obtained after local intra-arterial urokinase therapy confirming recanalization of the left middle cerebral artery by the distal vascular blush.

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    Follow-up left internal carotid arteriograms, lateral (left) and anteroposterior (right) views, obtained 6 months after surgery, showing complete recanalization of the left middle cerebral artery and no residual arteriovenous malformation nidus.

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