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Decision-making in a patient with cardiac arrest due to venous thromboembolism within 24 h after glioblastoma resection

  • Case Report - Brain Tumors
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Abstract

In the fulminant VTE form with cardiac arrest, systemic thrombolysis remains the most effective therapy. However, several contraindications restrict the use such as intracranial neoplasm or a recent history of intracranial surgery. Here, we report the case of a 59-year-old man who underwent glioblastoma resection and suffered from a fulminant pulmonary embolism with cardiac arrest. After CPR, continuous tPA infusion via an endovascularly placed pulmonary catheter was maintained over a period of 8 h. In this case, we report on our decision-making process and the use of local thrombolysis as a successful therapy in a patient with multiple contraindications.

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Abbreviations

LMWH:

Low molecular weight heparin

VTE:

Venous thromboembolism

ROSC:

Return of spontaneous circulation

GBM:

Glioblastoma multiforme

rtPA:

Recombinant tissue plasminogen activator

5-ALA:

5-aminolevulinic acid

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Acknowledgments

This study was possible only due to the interdisciplinary work performed by the staff of the Goethe University Hospital Frankfurt. DD provided clinical care to the patient and wrote and edited the manuscript. S-YW, MB, and M-TF provided clinical care to the patient. CS provided clinical assessment and supervised the manuscript. JB was involved in diagnostic and patient treatment. VS performed the operation and provided critical supervision of the manuscript and the study. JM provided clinical care to the patient and edited and directed the study.

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Authors and Affiliations

  1. Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany

    D. Dubinski, S-Y. Won, M. Bruder, M-T. Forster, V. Seifert, C. Senft & J. Mersmann

  2. Institute of Neuroradiology, Goethe University, Frankfurt, Germany

    J. Berkefeld

  3. Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University, Frankfurt, Germany

    J. Mersmann

Authors
  1. D. Dubinski
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  2. S-Y. Won
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  3. M. Bruder
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  4. M-T. Forster
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  5. V. Seifert
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  6. C. Senft
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  7. J. Berkefeld
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  8. J. Mersmann
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Corresponding author

Correspondence to D. Dubinski.

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Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Funding

No funding was received for this research.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Comments

The authors report a successful outcome after a PE-related cardiac arrest and subsequent treatment with intra-pulmonary artery lysis therapy with recombinant tissue plasminogen activator (rtPA), this all occurring only 24 h after a craniotomy and debulking of a left temporal lobe GBM.

Whilst the authors are to be congratulated on the high level of care offered in such an acute setting, this case does raise other issues, with perhaps a more likely outcome (if the patient survived at all) of significant neurological disability as a result of hemorrhage into the tumor resection bed. Is perhaps the paucity of reports of successfully treated patients in the literature is a reflection of this more likely outcome?

Most surgeons would undoubtedly have tried to resuscitate their patient given similar circumstances, but would most patients want such treatment if they knew the risks associated with the acute treatment and the natural history of GBM? Unfortunately, due to the acute way that most patients with GBM present, it is unlikely that they or their families are truly in a position to consent to anything but the primary procedure.

Paul Chumas

Leeds, UK

Dubinski and colleagues report an interesting case of successful selective pulmonary artery lysis therapy of a 59-year-old patient suffering from "cardiac arrest due to venous thromboembolism within 24 h after glioblastoma resection". This is especially interesting, since this lysis therapy has been used off-label. However, without this off-label use the patient would have died in all likelihood. This case report should also encourage other authors who may have performed off-label therapy in cases their patients would otherwise have died to publish their cases in order to give the readers inspiration on the one hand and to provide arguments in case of medicolegal difficulties.

Marcus Reinges

Giessen, Germany

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Dubinski, D., Won, SY., Bruder, M. et al. Decision-making in a patient with cardiac arrest due to venous thromboembolism within 24 h after glioblastoma resection. Acta Neurochir 158, 2259–2263 (2016). https://doi.org/10.1007/s00701-016-2982-2

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  • DOI: https://doi.org/10.1007/s00701-016-2982-2

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