Urokinase in the Treatment of Shunt Malfunctions Caused by Thrombus

Abstract

Thrombus is a frequent cause of shunt malfunction both of the proximal end following intraventricular hemorrhage and of the distal catheter of a vascular shunt. Continued blockages may result in numerous shunt revisions until the blood has been cleared. We have treated 3 children with shunt malfunctions secondary to thrombus with urokinase, a thrombolytic agent. Two children had intraventricular hemorrhage following a shunt revision and were treated with intrashunt urokinase, and 1 with occlusion of an atrial catheter was treated with both intrashunt and systemic urokinase. All were symptomatic at the time of treatment (headaches, vomiting, full fontanel, somnolence) and all had ventriculomegaly demonstrated on computed tomography. Various dosage regimens were used with total intrashunt doses of 20,000, 50,000, and 70,000 IU. All improved clinically, computed tomography scans demonstrated improvement, and all were discharged from the hospital. There were no complications of the urokinase administration. The 2 children with proximal occlusion have not required further shunt revisions at 12 and 27 months following treatment. The infant with atrial end occlusion subsequently underwent two proximal revisions with eventual removal of the atrial catheter because of infection. We conclude the intrashunt urokinase can be of value in the treatment of shunts by blood and blood products.

Shunt Revision by Coagulation with Retention of the Ventricular Catheter

“…The ventricular catheter is then removed and replaced. In our experience [5], and that of others [2], while this technique allows removal of adherent catheters, hemorrhage may still occur when the catheter is removed.…”

Ventricular reservoirs and ventriculoperitoneal shunts for premature infants with posthemorrhagic hydrocephalus: an institutional experience

“…25 Various treatment options have been proposed to manage posthemorrhagic hydrocephalus in preterm infants. 8,[12][13][14]20,24,26,27 In this paper we present our experience with 32 infants who presented with neonatal posthemorrhagic hydrocephalus.…”

Thrombosis associated with ventriculoatrial shunts

“…An increasing body of evidences suggests that intrareservoir administration of thrombolytic therapy can be a useful nonoperative treatment strategy for shunt malfunction associated with thrombsis [ 11 , 55 ]. Recombinant tissue-type plasminogen activator, streptokinase, and urokinase have been successfully used in management of many patients having an intracardiac thrombus [ 11 , 13 , 56 , 57 ]. Timely diagnosis by echocardiography before a thrombus gets bigger or organized leads to effective, safe, and rapid thrombolysis by use of thrombolytic drugs [ 55 ].…”

“…Removal of the VAS may not be an option in all patients. There have been reports of the use of thrombolytic agents and/or anticoagulation therapy to correct malfunction caused by thrombosis [ 11 , 14 , 56 ]. But those patient are prone to have a recurrence of thrombosis following cessation of therapy [ 14 ].…”