Recombinant human tissue plasminogen activator for chronic subdural hematoma [Neurosurgery Wiki]

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====== Recombinant human tissue plasminogen activator for chronic subdural hematoma ======

Two [[patient]]s presented with altered mental status secondary to acute-on-[[chronic subdural hematoma]]s and underwent emergent craniotomies. The first, a 78-year-old man, had poor [[subdural drain]] output and deteriorated with [[seizure]]s 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.

Subdural [[thrombolytic therapy]] can improve [[hematoma]] evacuation. A potential implication of this is the 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
((Lam J, Lee DJ, Oladunjoye A. Subdural Catheter Injection of Tissue Plasminogen
Activator for Residual Hematoma Post Drainage of Acute-on-Chronic Subdural
Hematoma: Novel Case Report of 2 Patients. World Neurosurg. 2020 Jan;133:266-270.
doi: 10.1016/j.wneu.2019.10.007. Epub 2019 Oct 9. PubMed PMID: 31605861.
))
((Lam J, Lee DJ, Oladunjoye A. In Reply to the Letter to the Editor Regarding
"Subdural Catheter Injection of Tissue Plasminogen Activator for Residual
Hematoma Post Drainage of Acute-on-Chronic Subdural Hematoma: Novel Case Report
of 2 Patients". World Neurosurg. 2020 Feb;134:681. doi:
10.1016/j.wneu.2019.11.175. PubMed PMID: 32059288.))
((Zhang J, Wang H, Li Y, Dong L. Letter to the Editor Regarding "Subdural
Catheter Injection of Tissue Plasminogen Activator for Residual Hematoma Post
Drainage of Acute-on-Chronic Subdural Hematoma: Novel Case Report of 2 Patients".
World Neurosurg. 2020 Feb;134:680. doi: 10.1016/j.wneu.2019.11.125. PubMed PMID: 
32059287.)).
----
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
((Brazdzionis J, Patchana T, Wiginton JG 4th, Wacker MR, Menoni R, Miulli DE.
Intracatheter Tissue Plasminogen Activator for Chronic Subdural Hematomas after
Failed Bedside Twist Drill Craniostomy: A Retrospective Review. Cureus. 2019 Dec 
26;11(12):e6472. doi: 10.7759/cureus.6472. PubMed PMID: 32025399; PubMed Central 
PMCID: PMC6984181.)).

----
Lam et al. presented the first case report of the safe use of [[tPA]] in conjunction with an Integra Camino bolt for maximized drainage of CSDH with a successful neurological recovery and the complete resolution of the hematoma
((Lam J, Lee DJ, Oladunjoye A. Subdural Catheter Injection of Tissue Plasminogen
Activator for Residual Hematoma Post Drainage of Acute-on-Chronic Subdural
Hematoma: Novel Case Report of 2 Patients. World Neurosurg. 2020 Jan;133:266-270.
doi: 10.1016/j.wneu.2019.10.007. Epub 2019 Oct 9. PubMed PMID: 31605861.)).
----



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