Arteriovenous malformation presenting as traumatic subdural hematoma: A case report

Antiplatelets and antithrombotics in neurointerventional procedures: Guideline update

BACKGROUND

Antiplatelet and antithrombotic medication management before, during, and after neurointerventional procedures has significant practice variation. This document updates and builds upon the 2014 Society of NeuroInterventional Surgery (SNIS) Guideline 'Platelet function inhibitor and platelet function testing in neurointerventional procedures', providing updates based on the treatment of specific pathologies and for patients with specific comorbidities.

METHODS

We performed a structured literature review of studies that have become available since the 2014 SNIS Guideline. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors.

RESULTS

The management of antiplatelet and antithrombotic agents before, during, and after endovascular neurointerventional procedures continues to evolve. The following recommendations were agreed on. (1) It is reasonable to resume anticoagulation after a neurointerventional procedure or major bleeding episode as soon as the thrombotic risk exceeds the bleeding risk in an individual patient (Class I, Level C-EO). (2) Platelet testing can be useful to guide local practice, and specific approaches to using the numbers demonstrate marked local variability (Class IIa, Level B-NR). (3) For patients without comorbidities undergoing brain aneurysm treatment, there are no additional considerations for medication choice beyond the thrombotic risks of the catheterization procedure and aneurysm treatment devices (Class IIa, Level B-NR). (4) For patients undergoing neurointerventional brain aneurysm treatment who have had cardiac stents placed within the last 6-12 months, dual antiplatelet therapy (DAPT) is recommended (Class I, Level B-NR). (5) For patients being evaluated for neurointeventional brain aneurysm treatment who had venous thrombosis more than 3 months prior, discontinuation of oral anticoagulation (OAC) or vitamin K antagonists should be considered as weighed against the risk of delaying aneurysm treatment. For venous thrombosis less than 3 months in the past, delay of the neurointerventional procedure should be considered. If this is not possible, see atrial fibrillation recommendations (Class IIb, Level C-LD). (6) For patients with atrial fibrillation receiving OAC and in need of a neurointerventional procedure, the duration of TAT (triple antiplatelet/anticoagulation therapy=OAC plus DAPT) should be kept as short as possible or avoided in favor of OAC plus single antiplatelet therapy (SAPT) based on the individual's ischemic and bleeding risk profile (Class IIa, Level B-NR). (7) For patients with unruptured brain arteriovenous malformations there is no indication to change antiplatelet or anticoagulant management instituted for management of another disease (Class IIb, Level C-LD). (8) Patients with symptomatic intracranial atherosclerotic disease (ICAD) should continue DAPT following neurointerventional treatment for secondary stroke prevention (Class IIa, Level B-NR). (9) Following neurointerventional treatment for ICAD, DAPT should be continued for at least 3 months. In the absence of new stroke or transient ischemic attack symptoms, reversion to SAPT can be considered based on an individual patient's risk of hemorrhage versus ischemia (Class IIb, Level C-LD). (10) Patients undergoing carotid artery stenting (CAS) should receive DAPT before and for at least 3 months following their procedure (Class IIa, Level B-R). (11) In patients undergoing CAS during emergent large vessel occlusion ischemic stroke treatment, it may be reasonable to administer a loading dose of intravenous or oral glycoprotein IIb/IIIa or P2Y12 inhibitor followed by maintenance intravenous infusion or oral dosing to prevent stent thrombosis whether or not the patient has received thrombolytic therapy (Class IIb, C-LD). (12) For patients with cerebral venous sinus thrombosis, anticoagulation with heparin is front-line therapy; endovascular therapy may be considered particularly in cases of clinical deterioration despite medical therapy (Class IIa, Level B-R).

CONCLUSIONS

Although the quality of evidence is lower than for coronary interventions due to a lower number of patients and procedures, neurointerventional antiplatelet and antithrombotic management shares several themes. Prospective and randomized studies are needed to strengthen the data supporting these recommendations.

Spontaneous subdural hematoma concomitant with subarachnoid hemorrhage and intracerebral hemorrhage due to ruptured brain arteriovenous malformation treated with curative embolization

Introduction

An arteriovenous malformation (AVM) consists of a tangled cluster of dilated blood vessels forming anomalous communication between arterial and venous systems without capillary bridging. The most likely manifestations of a ruptured AVM are intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or intraventricular hemorrhage (IVH). Subdural hematoma (SDH) is exceptional in cases of ruptured brain arteriovenous malformation (BAVM).

Case Report

A 30-year-old female was referred to the Emergency Room with a major complaint of sudden thunderclap headache 1 day before admission. The patient also complained of double vision and left ptosis that lasted for 1 day. There was no other complaint or history of hypertension, diabetes, or trauma. Non-contrast head computed tomography (CT) showed ICH-SAH-SDH on the left side of the brain which was not typical of a hypertensive pattern. The secondary ICH has a score of 6, indicating that 100% of the bleeding might be caused by underlying vascular malformation. Furthermore, cerebral angiography showed cortical plexiform BAVM on the left occipital lobe, and the patient underwent curative embolization.

Discussion

Spontaneous SDH is very rare, and there are some hypotheses about the reasons for its occurrence. First, brain movement stretches the arachnoid layer that adheres to the AVM, resulting in direct bleeding into subdural space. Second, high-flow pia-arachnoid ruptured blood might extravasate into subdural space. Finally, the ruptured cortical artery that connects the cortex and dura layer (bridging artery) might also cause SDH. Some scoring systems are useful in BAVM, and this study selected endovascular embolization for the patient.

Conclusion

Brain AVM rupture usually causes ICH, SAH, or IVH. Clinicians must be more aware of spontaneous SDH because it might be caused by a vascular malformation, although it is rare.

Acute spontaneous subdural hematoma secondary to ruptured arteriovenous malformation: A rare entity

Introduction

Acute spontaneous subdural hematoma (ASSDH) due to ruptured arteriovenous malformation (AVM) is exceptional. There were only four reported cases. In this paper, we present a successful multimodality treatment of the ASSDH secondary to ruptured AVM.

Case presentation

A 21-year-old healthy man with no history of trauma presented to our hospital with complaints of severe headache for 12 hours before admission. On examination, he was alert and oriented. He had no intracranial hypertension, meningismus, and neurological deficits. Computed tomography illustrated a right acute subdural hematoma 8mm in thickness with a 5mm midline shift and a right frontal intraparenchymal hemorrhage 40 × 25mm in size. Digital subtraction angiography showed a 2 × 3 cm right frontal AVM, Spetzler-Martin grade I. The feeding arteries were cortical branches of the right anterior cerebral artery, and drain veins were cortical veins. He received emergency preoperative embolization followed by hematoma evacuation and total excision of the malformation. His headache was relieved and disappeared after a week. No postoperative neurological deficits were reported.

Clinical discussion

Elective surgical resection of AVM after 4–6 weeks was preferred in patients with no risk factors of rebleeding. Emergent surgery was only indicated for significant mass effect or acute hydrocephalus. Preoperative embolization is helpful for the presence of intra-nidal or peri-nidal aneurysm, AVM with high grades, reducing intraoperative blood loss and occlusion of deep vessels.

Conclusion

ASSDH due to ruptured AVM is rare and easy to omit in clinical settings. Preoperative embolization and surgical excision are effective treatments.

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Acute spontaneous SDH due to ruptured AVM is quite rare and easy to omit in clinical settings.

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Prompt CTA or MRA should be considered initial screening tools when available to rule out a ruptured AVM.

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Preoperative embolization and surgical excision are the mainstays of treatment of ruptured AVMs.