Treatment of a recurrent subdural hematoma using urokinase

Urokinase Salvage Therapy for Recurrent Chronic Subdural Hematoma Caused by Dual Antiplatelet Therapy

Chronic subdural hematoma (cSDH) is one of the most common neurosurgical conditions among older adults. Here, we describe a case of recurrent cSDH resulting from seven days of dual antiplatelet therapy. A 76-year-old woman reported a headache resembling a chronic tension-type headache for the last 10 days. MRI revealed a right parietal cSDH and left frontoparietal cSDH. Single burr-hole aspiration and irrigation technique with continuous closed subdural drainage was performed bilaterally under general anesthesia. The patient experienced two bouts of transient ischemic attack and received seven days of dual antiplatelet therapy. On the 12th day after the initial surgery, the patient underwent another operation to re-evacuate the cSDH. Considering that the color of the output fluid persisted as oil-black and the average net output was 12.5 cc/day, we decided to use urokinase to restore the patency of the drainage catheter. In the early postoperative phase after the second surgery, a total of 20,000 units of urokinase was injected into the subdural space. On the 10th postoperative day, the patient was discharged home. In patients with cSDH presenting with obvious postoperative hematoma residue, the routine use of subdural injection of urokinase could be a new direction in cSDH management.

Fibrinolytic-Facilitated Chronic Subdural Hematoma Drainage-A Systematic Review

BACKGROUND

The current treatment options for chronic subdural hematoma (CSDH) include burr hole drainage, twist drill drainage, and craniotomy with or without postoperative catheter drainage. Although generally effective, these treatments have continued to be complicated by recurrence, especially in partially hemolyzed or septated hematomas. Recently, interest in the use of fibrinolytic agents as an adjunct to surgical treatment to address this limitation has been increasing. We conducted a systematic review, focusing on the efficacy and safety profile of fibrinolytic agents and compared the different fibrinolytic agents.

METHODS

The PubMed, EMBASE, CINAHL Plus, and Cochrane Library databases were searched for trials relevant to fibrinolytic administration in the treatment of CSDH. The findings are reported in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The data from 1702 subjects from 6 retrospective observational studies were qualitatively analyzed. In addition, we included 11 case series and reports for discussion.

RESULTS

For 1449 patients, the use of urokinase or tissue plasminogen activator improved hematoma drainage and shortened the hospital stay (7.04 days), with an overall hematoma recurrence rate of 1.59%. The incidence of infection, seizure, and intracranial bleeding was 3.18%, 0.80%, and 0.41%, respectively, which compared favorably with previously reported findings for surgical drainage without the use of fibrinolytic agents.

CONCLUSIONS

The routine use of intrathecal urokinase and tissue plasminogen activator could be a new direction in the management of CSDH. Conclusive clinical evidence is lacking, however, and further prospective controlled studies are warranted to confirm the benefit and safety of this treatment strategy and to identify the optimal agent and dosing regimen.

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

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.

How to Treat Chronic Subdural Hematoma? Past and Now

Treatment of chronic subdural hematoma (CSDH) is relatively straightforward, however, there is still some debate regarding the best strategy for treatment. The most practical recommendations of up to date were identified by a review of literature. The author reviewed the literature on CSDH management from the past to now to identify the best methods. Till 1970s, craniotomy was the most commonly used method. Burr hole (BH) became the most preferred method from 1980s. In 1977, twist drill (TD) craniostomy was introduced. Closed system drainage after a BH or a TD became the most frequently used surgical method. Although nonsurgical treatment is often successful, trephination has more advantages, such as rapid resolution of the symptoms and short period of hospitalization. Nonsurgical treatment is possible in asymptomatic patients with a small CSDH. For the symptomatic patients with CSDH, trephination is the treatment of choice, either by BH or TD. In gray zone between surgery and medical treatment, shared decision making can be an ideal approach. For the recurrent CSDHs, repeated trephination is still effective for patients with a low risk of recurrence. If the risk of recurrence is high, additional management would be helpful. For the refractory CSDHs, it is necessary to obliterate the subdural space.

Burr Hole Drainage with Urokinase Irrigation for the Treatment of Acute Subdural Hematoma: A Case Report

We describe the case of a patient with an acute subdural hematoma (SDH) that was removed using urokinase irrigation after burr hole trephination in a limited situation where craniotomy was not possible. A 90-year-old woman was admitted to our hospital with a stuporous mental status. Computed tomography (CT) scans revealed a chronic SDH, and a burr hole procedure was performed. The patient's postoperative progression was good until the third day after surgery when we found that the acute SDH had increased on CT scans. The patient's guardian refused further surgery, and thus we drained the blood from the hematoma by injecting urokinase through a drainage catheter. We used urokinase for two days, and removed the catheter after confirming via CT scans that the hematoma was almost alleviated. The patient recovered gradually; she was discharged with few neurological deficits.

Chronic subdural haematoma: surgical treatment and outcome in 1000 cases

Chronic subdural haematoma (CSDH) is one of the most common clinical entities in daily neurosurgical practice. To evaluate the clinical features, computed tomography findings, surgical results, and complications our series was statistically analysed to elucidate the factors affecting the post-operative outcome. A retrospective study (1980-2002) of the records of 1000 patients harbouring 1097 chronic subdural haematoma treated with burr-hole craniotomy with closed-system drainage was carried out. The series included 628 males and 372 females, age range 12-100 years, mean age 72.7+/-11.4 years. The mean interval from trauma to appearance of clinical symptoms was 49.1+/-7.4 days (15-751). The principal symptom was headache (29.7%) in the over 70s, and behavioural disturbance (33.8%) in the under 70s. The CSDH was right sided in 432 patients, left sided in 471, and bilateral in the remaining 97 cases. Post-operative complications occurred in 196 patients and 21 patients died in hospital. Poor prognosis was related to patient's age (>70) and clinical grade on admission (grades 0-2 versus grades 3-4).

[Chronic subdural hematoma in patients over 80 years of age]

INTRODUCTION

Chronic subdural hematoma (CSH) represents one of the most frequent types of intracranial hemorrhage. Most occur in elderly patients causing a variety of therapeutic problems associated to systemic diseases.

PATIENTS AND METHODS

A retrospective study of 90 patients older than 80 years of age with chronic subdural hematoma treated in the last 15 years was undertaken. For clinical evaluation on admission and at discharge we used the classification of Markwalder. Surgical treatment was performed in all patients and a burr hole craniostomy with closed drainage system was used.

RESULTS

On admission, 73 patients (80%) were in satisfactory condition (grades 0-2); 17 (20%) were grade 3 or 4. Seven (7.7%) patients died but none due to surgery. In 6 (6.6%) of the patients, surgical reintervention was required to remove a recurring CSH. In 76.6% of the patients, the results achieved were graded 0 or 1.

CONCLUSIONS

In our experience CSH in elderly patients should be treated with minimal surgery with a simple drainage of the subdural space. The good results suggest that the procedure could be considered as a first procedure in these patients and that age or concomitant diseases do not appear to be poor prognostic factors.