Delayed Operation of Acute Subdural Hematoma in Subacute Stage by Trephine Drainage using Urokinase

Abstract

Objective: The principle operation of acute subdural hematoma (ASDH) is a craniotomy with hematoma removal, but a trephination with hematoma evacuation may be another method in selected cases. Trephine drainage was performed for ASDH patients in subacute stage using urokinase (UK) instillation, and its results were evaluated. Methods: Between January 2016 and December 2018, the trephine evacuation using UK was performed in 9 patients. The interval between injury and operation was from 1 to 2 weeks. We underwent a burr hole trephination with drainage initially, and waited until the flow of liquefied hematoma stopped, then instilled UK for the purpose of clot liquefaction. Results: The mean age of patients was 71.6 years (range, 38-90 years). The cause of ASDH was trauma in 8 cases, and supposed a complication of anticoagulant medication in 1 case. Four out of 8 patients took antiplatelet medications and one of them was a chronic alcoholism. The range of the Glasgow Coma Scale score before surgery was from 13 to 15. Most of patients, main symptom was headache at admission. The Glasgow Outcome Scale score was 5 in 8 cases and 3 in 1 case. Conclusion: It is thought to be a useful operation method in selected patients with ASDH that the subdural drainage in subacute stage with UK instillation. This method might be another useful option for the patients with good mental state regardless of age and the patients with a risk of bleeding due to antithrombotic medications.

Acute-to-chronic subdural hematoma: radiographic and clinical progression from acute subdural hematoma

“…Kpealo et al reported onset of symptoms after trauma with ASDH after 27.4 days in case of CSDH and 12.6 days in case of subacute SDH [ 19 ]. In a study by Kang et al, 9 patients with SDH in the subacute stage were treated via burr hole trephination and injection of urokinase in patients with increased midline shift or clinical deterioration after 10.2 days of trauma with ASDH [ 15 ]. Other studies reported similar time periods with mean number of days between 11 and 18 after trauma with ASDH and burr hole trephination for liquefied subdural hematoma [ 1 , 6 , 13 ].…”

“…On the one hand, identifying patients at risk is beneficial for clinical monitoring of these ASDH patients, and on the other hand, knowledge about the clinical and radiographic progression from ASDH to CSDH within the days and weeks after trauma is important for monitoring and early adequate treatment of these patients. The course of these patients has only been reported in some small case series [ 1 , 6 , 15 , 19 ]. Also, limited data is available about potential differences of this form of CSDH and the conventional CSDH form which usually develops over a longer period of time [ 7 , 10 ].…”