Subdural Catheter Injection of Tissue Plasminogen Activator for Residual Hematoma Post Drainage of Acute-on-Chronic Subdural Hematoma: Novel Case Report of 2 Patients

Lam, Jørgen; Lee, Darrin J.; Oladunjoye, Azeem

doi:10.1016/j.wneu.2019.10.007

Cited by 8 publications

(4 citation statements)

References 15 publications

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“…With our understanding of the pathophysiology, we recommend inner membrane membranotomy under direct visualization to facilitate brain expansion, decrease stretching of the cortical vessels, and prevent SDH recurrences [6][7][8]. If there is still failure at this point, then another craniotomy or tPA administration after craniotomy can be considered [30,31]. None of the patients treated with the algorithm needed postcraniotomy tPA administration.…”

Section: Discussionmentioning

confidence: 99%

An Algorithm for Treatment of Symptomatic Chronic Subdural Hematomas

Wang,

Rahman,

Ueno

et al. 2024

Cureus

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Introduction: Although chronic subdural hematoma (CSDH) is a common neurosurgical disease, there is a lack of algorithms for the treatment of asymptomatic and symptomatic CSDH. The purpose of this article is to describe an algorithm developed using our institutional experience for the treatment of symptomatic CSDH that aims to decrease symptoms and/or hematoma size or to completely resolve both. Our algorithm for treatment of symptomatic CSDH includes subdural drain (SDD) placement via twist-drill craniostomy (TDC) as the first-line treatment, followed by supplemental tissue plasminogen activator (tPA) as secondline treatment, with possible middle meningeal artery embolization (MMAE), followed by craniotomy as the last therapeutic option. This study investigated the efficacy of our institution's algorithm in treating symptomatic CSDH.Methods: A retrospective study was conducted from 2019 to 2023 identifying patients with CSDH treated with TDC. Electronic medical records were used to gather patient demographics, clinical presentation, radiographic findings, treatment modalities, and clinical outcomes.Results: There were a total of 109 patients with 128 SDD placements. All 109 patients underwent TDC; among them, 37 patients received tPA instillation with three patients requiring craniotomy. Factors including age, gender, race, mechanism of injury, blood thinner usage, Glasgow Coma Scale (GCS), neurologic exam, thickness of CSDH, and midline shift were comparable for all patients regardless of treatment received. The mean number of neomembranes was higher in patients who eventually required craniotomy (4.5) compared to those treated with TDC only (1.8) and TDC+tPA (2.1) (p=0.0035). There was a greater mean hematoma drainage in patients who received tPA instillation without craniotomy (586.7 mL) than those treated with TDC only (293.0 mL) (p<0.0001). Clinical improvement was found in 52/72 patients (72.2%) treated with TDC only, 23/34 patients (67.6%) treated with TDC+tPA only, and 0/3 patients (0.0%) treated with TDC+tPA+craniotomy. Radiographic improvement in mean thickness of CSDH and midline shift, respectively, was found in patients treated with TDC only (p<0.0001; p<0.0001) and TDC+tPA (p<0.0001; p<0.0001) but not in TDC+tPA+craniotomy (p=0.1494; p=0.0762). There were also fewer neomembranes after TDC+tPA treatment only (2.1 vs. 0.5, p<0.0001). Seven patients were readmitted that did not follow the algorithm and only patients treated following the algorithm showed clinical and radiographic improvement.Conclusions: Using our institutional algorithm, our study demonstrates successful clinical outcomes in treating symptomatic CSDH and recurrent CSDH with minimally invasive therapeutic interventions including SDD via TDC and tPA, thereby minimizing the utilization of more invasive interventions including craniotomy.

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Section: Discussionmentioning

confidence: 99%

An Algorithm for Treatment of Symptomatic Chronic Subdural Hematomas

Wang,

Rahman,

Ueno

et al. 2024

Cureus

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“…Other authors also reported the use of subdural r-tPA application for acSDH, using traditional catheters, with good results, considering that r-tPA has more specificity to fibrin compared to Urokinase [ 10 ]. The anti-thrombotic catheter can improve the proximal risk of obstruction by clots, being a feasible alternative to the traditional catheter.…”

Section: Discussionmentioning

confidence: 99%

Burr Hole Hematoma Evacuation of Large Subdural Component Using Recombinant Tissue-Type Plasminogen Activator and a Novel Catheter: Case Report

Mônaco¹,

Krueger²,

Soldozy³

et al. 2022

Cureus

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The large acute component in a chronic subdural hematoma (cSDH) typically requires a craniotomy. Open surgery can be associated with increased morbidity and is not always possible due to systemic conditions. We present the case of a 58-year-old patient who presented with a Glasgow Coma Scale (GCS) of three fixed pupils, but remaining brainstem reflexes were present. Brain CT showed a large mixed subdural left chronic hematoma, with a predominant acute component, with a 26mm midline shift. The patient was hemodynamically unstable and coagulopathic; thus, emergency bedside burr hole evacuation was done. An “anti-thrombotic catheter” was left in the subdural space as a postoperative drain. Postoperatively, GCS improved, and CT presented a residual 12.7mm midline shift due to the acute bleeding component. Recombinant tissue-type plasminogen activator (r-tPA) solution was repeatedly administered using the catheter for two days, and it continued to drain for 10 more days with no additional dose. The patient presented clinical and radiological improvement with the dissolution of the acute component. This case is the first description of local subdural use of r-tPA to treat the acute component of cSDH with success associated with an anti-thrombotic catheter.

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“…Due to the growing aging population, the incidence of ASDH has been continuously rising with increased comorbidities, disease severity, and anticoagulant use. [2][3][4][5][6] Early reduction in brain shifting and decompression of increased intracranial pressure are essential to reduce the duration of ischemic brain injury, and urgent surgical treatment through large craniotomy is recommended if the patient has consciousness impairment, worsening neurological symptoms, or cerebral midline shift (MLS) caused by a large amount of hematoma as detected on brain computed tomography (CT). [5,[7][8][9][10][11][12] A large craniotomy is traditionally recommended as the first-line treatment for ASDH.…”

Section: Introductionmentioning

confidence: 99%

“…Due to the growing aging population, the incidence of ASDH has been continuously rising with increased comorbidities, disease severity, and anticoagulant use. [2–6]…”

Section: Introductionmentioning

confidence: 99%

Minimally invasive fibrinolytic treatment and drainage in patients with acute subdural hemorrhage and underlying comorbidities

et al. 2022

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The incidence of acute subdural hemorrhage (ASDH), which is often caused by head trauma, is steadily increasing due to an increase in the elderly population and the use of anticoagulants. Urgent surgical treatment is recommended if the patient has impaired consciousness, worsening neurological symptoms, or brain midline shift (MLS) due to large hematomas on brain computed tomography (CT). Although large craniotomy is traditionally recommended for ASDH removal, old age, comorbidities, and antiplatelet drugs are considered risk factors for surgical complications, many neurosurgeons hesitate to perform aggressive surgical procedures in these patients. In this study, we introduced a method that can quickly and effectively remove ASDH without general anesthesia. We retrospectively reviewed 11 cases of patients with ASDH who underwent hematoma drainage between June 2019 and December 2020. We measured the maximum subdural hematoma thickness and MLS on brain CT of patients and recorded the Glasgow Coma Scale scores before and after the surgical procedure. All patients had multiple comorbidities, and seven patients received anticoagulant or antiplatelet therapy. On initial brain CT, the median subdural hemorrhage thickness was 21.36 mm, median MLS was 10.09 mm, and mean volume of the subdural hematoma was 163.64 mL. The mean evacuation rate of the subdural hematoma after drainage was 83.57%. There was no rebleeding or operation-related infection during the aspiration procedure, and the median MLS correction after the procedure was 7.0 mm. Our treatment strategies can be a reliable, less invasive, and alternative treatment option for patients at high risk of complications due to general anesthesia or patients who are reluctant to undergo a large craniotomy due to a high bleeding tendency.Abbreviations: ASDH = acute subdural hematoma, CT = computed tomography, EVD = external ventricular drainage, GCS = Glasgow coma scale, MLS = midline shifting, mRS = modified Rankin Scale, rtPA = recombinant tissue plasminogen activator.

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Subdural Catheter Injection of Tissue Plasminogen Activator for Residual Hematoma Post Drainage of Acute-on-Chronic Subdural Hematoma: Novel Case Report of 2 Patients

Cited by 8 publications

References 15 publications

An Algorithm for Treatment of Symptomatic Chronic Subdural Hematomas

An Algorithm for Treatment of Symptomatic Chronic Subdural Hematomas

Burr Hole Hematoma Evacuation of Large Subdural Component Using Recombinant Tissue-Type Plasminogen Activator and a Novel Catheter: Case Report

Minimally invasive fibrinolytic treatment and drainage in patients with acute subdural hemorrhage and underlying comorbidities

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