Jordan Lam1, Darrin J Lee2, Azeem Oladunjoye3. 1. Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA. Electronic address: Jordan.lam@med.usc.edu. 2. Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA. 3. Department of Neurosurgery, San Joaquin General Hospital, French Camp, California, USA.
Abstract
BACKGROUND: Residual hematoma after operative management of acute subdural hematoma contributes to reoperation and is cited as a reason for deferment of less invasive drainage strategies. Although local antithrombolytic therapy has been studied in intracerebral hemorrhage and chronic subdural hematoma, to date there are no reports of recombinant tissue plasminogen activator for residual hematoma post drainage for acute subdural hematoma. CASE DESCRIPTION: Two patients presented with altered mental status secondary to acute-on-chronic subdural hematomas and underwent emergent craniotomies. The first, a 78-year-old man, had poor subdural drain output and deteriorated with seizures and evidence of new acute subdural hematoma formation. Recombinant tissue plasminogen activator was injected through the subdural catheter on postoperative day 3. The second patient, a 64-year-old male, received recombinant tissue plasminogen activator postoperatively. Subsequently, both experienced good subdural drainage, clinical and radiologic improvement, and successful discharge to a skilled nursing facility. CONCLUSIONS: Subdural thrombolytic therapy can improve hematoma evacuation. A potential implication of this is facilitation of minimally invasive options such as twist-drill craniotomy, previously deferred due to inadequate evacuation. However, there is a paucity of evidence and more research is needed to substantiate the safety and efficacy, refine this technique, and guide patient selection.
BACKGROUND: Residual hematoma after operative management of acute subdural hematoma contributes to reoperation and is cited as a reason for deferment of less invasive drainage strategies. Although local antithrombolytic therapy has been studied in intracerebral hemorrhage and chronic subdural hematoma, to date there are no reports of recombinant tissue plasminogen activator for residual hematoma post drainage for acute subdural hematoma. CASE DESCRIPTION: Two patients presented with altered mental status secondary to acute-on-chronic subdural hematomas and underwent emergent craniotomies. The first, a 78-year-old man, had poor subdural drain output and deteriorated with seizures and evidence of new acute subdural hematoma formation. Recombinant tissue plasminogen activator was injected through the subdural catheter on postoperative day 3. The second patient, a 64-year-old male, received recombinant tissue plasminogen activator postoperatively. Subsequently, both experienced good subdural drainage, clinical and radiologic improvement, and successful discharge to a skilled nursing facility. CONCLUSIONS: Subdural thrombolytic therapy can improve hematoma evacuation. A potential implication of this is facilitation of minimally invasive options such as twist-drill craniotomy, previously deferred due to inadequate evacuation. However, there is a paucity of evidence and more research is needed to substantiate the safety and efficacy, refine this technique, and guide patient selection.