Intracatheter Tissue Plasminogen Activator for Chronic Subdural Hematomas after Failed Bedside Twist Drill Craniostomy: A Retrospective Review

Abstract

Introduction Chronic subdural hematomas (cSDH) are common in neurosurgery with various symptoms and significant morbidity and mortality. Treatment varies with procedures including twist-drill (TD) craniostomy, craniotomy, burr hole craniostomy, and craniectomy. Newer treatments including middle meningeal artery embolization are also being explored as no treatment has been determined to be optimal. Due to the lack of consensus treatment, tissue plasminogen activator (tPA) has begun to be investigated to promote drainage and has shown promise in some early studies in reducing recurrence rates. We retrospectively reviewed patients who underwent TD craniostomy and received intracatheter tPA to evaluate the safety and efficacy of this practice. Methods A single-center retrospective review from December 2018 through August 2018 occurred for patients with cSDH 18 years of age or older who underwent a bedside TD craniostomy. Inclusion criteria included all patients who underwent treatment with TD craniostomy for drainage of cSDH during the time period in which tPA protocol was adopted as a possible therapeutic measure at our center. Exclusion criteria included all patients less than age 18 or incarcerated. Patients were stratified into two groups those that received tPA per our center's neurosurgical protocol and those that received drainage alone. Data collected included demographics, hospital/intensive care unit (ICU) length of stay, operative intervention, cSDH thickness throughout stay, length of drainage, and Glasgow Coma Scale (GCS) on arrival and discharge with analysis performed using t-tests. Results In all, 20 patients met inclusion: six received tPA at 48 hours per the institutional neurosurgical protocol and 14 did not. The average thickness of cSDH on arrival was significantly larger in the tPA group (26.5 mm vs 14.46 mm, p = 0.0029). Arrival and discharge GCS, average daily drainage, length of stay parameters, and percent change in thickness did not differ between tPA and no tPA groups. The average daily drainage was significantly less prior to the administration of tPA in the tPA group than in the cohort of not receiving tPA (30.71 mL vs 68.99 mL; p = 0.011). Average drainage in patients who received tPA after administration was significantly higher compared to pre-tPA values (131.39 mL vs 30.71 mL; p = 0.046). No patients were readmitted for re-accumulation or required an operating room procedure. There were no adverse outcomes identified through the instillation of tPA. Conclusion Intracatheter tPA increased drainage rates in the assessment of pre- and post-tPA values when administered at 48 hours after subdural drain (SDD) placement. Patients who received benefits from tPA tended to have larger subdural hematomas and less drainage prior to the instillation of tPA than patients that benefited from drainage alone. Larger prospective studies should investigate early treatment with tPA to identify if tPA is efficacious for all patients after TD craniostomy and to optimize patient selection with regard to thrombolytic therapy.

Keywords: chronic; chronic subdural hematoma; efficacy; safety; subdural; subdural drainage; subdural hematoma; tissue plasminogen activator; tpa; twist drill craniostomy.

Conflict of interest statement

The authors have declared that no competing interests exist.

Copyright © 2019, Brazdzionis et al.

Figures

Figure 1. Pre-drainage CT scan of a patient who underwent subdural drain placement with tissue plasminogen activator adjunct

Thickness was measured at approximately 28 mm; the arrow is pointing to the location of the subdural hematoma providing significant mass effect.

Figure 2. Pre-tissue plasminogen activator CT scan of a patient who underwent subdural drain placement with tissue plasminogen activator adjunct

This image was taken prior to the initiating protocol for the administration of tissue plasminogen activator through the subdural drain. Mass effect is decreased but still present from the subdural hematoma, marked by the arrow compared to figure 1. Some pneumocephalus is present from initial drain placement and there is evidence of some post-traumatic hemorrhage caused by drain placement.

Figure 3. Post-tissue plasminogen activator and prior to discharge CT scan of a patient who underwent subdural drain placement with tissue plasminogen activator adjunct

After the initiation of tissue plasminogen activator, the patient had increased drainage. This patient had significantly decreased mass effect and size of the subdural hematoma, marked by the arrow, after the initiation of tissue plasminogen activator protocol.